May/June - West Virginia State Medical Association

Transcription

Health System
Reform
The Inside Story
The Fight is on!
Med-Mal Caps Challenge
Heads to WV Supreme Court
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WVUVascular:GKad
4/13/10
8:01 AM
Page 1
Lakshmikumar Pillai, MD
Alexandre d’Audiffret, MD
Inside FRONT
Pamela Zimmerman, MD
Vascular Surgery
Advances
at WVU
This spring marks the opening
of a state-of-the-art, dedicated Interventional Radiology room for vascular
procedures at WVU. Our ﬁxed imaging technology yields the most highly detailed,
real-time images available, while minimizing the patient’s exposure to radiation.
WVU’s vascular IR room is an unsurpassed environment for accurate and safe
vascular procedures.
The WVU vascular and endovascular surgeons perform a variety of open surgical
procedures for treating carotid, aneurysmal, and peripheral arterial disease. In
addition, we have an active program in endovascular intervention and minimally
invasive surgery, including:
• angiography (carotid to tibial, including renal)
• endovascular aneurysm repair (thoracic and abdominal)
using all of the current FDA-approved devices
• carotid artery angioplasty and stent placement
• dialysis access construction and intervention
• endovenous radio frequency/laser closure of varicose veins
For more information or to make referrals, call 800-WVA-MARS (982-6277) • wvuhealth.com
4/23/2010 3:14:47 PM
Continuing Medical Education
Opportunities at CAMC Health Education
and Research Institute
The CAMC Health Education and Research Institute is dedicated to improving health through
research, education and community health development. The Institute’s Education Division
offers live conferences, seminars, workshops, teleconferences and on-site programs to health
care professionals. The CAMC Institute’s CME program is accredited by the Accreditation
Council for Continuing Medical Education to sponsor continuing medical education for
physicians. The CAMC Institute designates this educational activity for a maximum of 1 AMA
PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the
extent of their participation in the activity. For more information on these and future programs
provided by the Institute, please call (304) 388-9960 or fax (304) 388-9966.
SEMInARS
27th Annual Newborn Day
Advanced Cardiovascular Life
Support (ACLS) – Renewal
Friday, May 7
Embassy Suites
Charleston, WV
May 6, 14, 17, 21
Pediatric Advanced Life
Support (PALS) - Renewal
Osteopathic Medicine
Symposium
May 5, 26
Thursday and Friday, May 13-14
Auditorium
Robert C. Byrd Health Sciences
Center of West Virginia
University-Charleston Division
Charleston, WV
May 18
Life Support Training
Log-on to our web site at www.
camcinstitute.org
Log-on to our web site to
register at www.camcinstitute.org
Advanced Cardiovascular Life
Support (ACLS) – Provider
May 3, 19
Simulated Sepsis Course
CME OnlInE
PROgRAMS/ARCHIvEd
guESt lECtuRE
PROgRAMS
System Requirements
Environment: Windows 98, SE,
NT, 2000 or XP
Resolution: 800 x 600
Web Browser: Microsoft’s
Internet Explorer 5.0 or above
or Netscape Navigator 4.7x. (Do
not use Netscape 7.1)
Video Player: Windows Media
Player 6.4 or better.
Dial-Up or Broadband
Connection. Minimum
Speed, 56k (Broadband is
Recommended)
OtHER ARCHIvEd CME
OPPORtunItIES:
Geriatric Series
Ethics Series
Research Series
NET Reach library
©Charleston Area Medical Center Health System, Inc. 2010
21894-B10
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contents
May/June 2010, Volume 106, No. 3
features
In this issue…
4 President’s Message
8 Our Editor Speaks
Scientific Articles
9 Guest Editorial
12 A Review of the American Heart Association Revised
36 General News
Guidelines for the Prevention of Infective Endocarditis
37 Photo montage—Haiti
16A Young Male with Sudden Onset Left-Sided
Weakness
38 SPECIALNews—Med Mal Challenge
19Free Muscle Flap Reconstructions Using Interpositional
39 Health System Reform—Its Impact on WV
Vein Grafts vs. Local Anastomosis: A 5-Year Experience
42 WESPAC Contributors
24Successful Pregnancy Following Conservative Surgical
Therapy of an Invasive Molar Gestation
43 WESPAC 2010 Primary Endorsements
26Geographic and Temporal Comparisons of ATV Deaths
44 2010 Legislative Wrap-Up
in West Virginia, 2000-2008
48 Robert C. Byrd Health Sciences Center of
West Virginia University News
Special Article
49 Marshall University Joan C. Edwards School
of Medicine News
Finding a Faster Route to Practice:
From Medical Student to
Board Certified Physician
50 West Virginia School of Osteopathic
Medicine News
30
51 Bureau for Public Health News
52 Physician Practice Advocate News
53 New Members
54 Obituaries
56 West Virginia Medical Insurance Agency News
Cover photo courtesy of
Angela S. Johnson
59 Classified Ads
60 Manuscript Guidelines/Advertisers
Editor
F. Thomas Sporck, MD, FACS
Charleston
Associate Editors
James D. Felsen, MD, MPH, Charleston
Robert J. Marshall, MD, Huntington
Managing Editor/Director of Communications
Douglas L. Jones, MD, White Sulphur Springs
David Z. Morgan, MD, Morgantown
Angela L. Lanham, Charleston
Steven J. Jubelirer, MD, Charleston
Martha D. Mullett, MD, Morgantown
Executive Director
Roberto Kusminsky, MD, MPH, FACS, Charleston
Louis C. Palmer, MD, Clarksburg
Evan H. Jenkins, Huntington
The West Virginia Medical Journal is published bimonthly by the West Virginia State Medical Association, 4307 MacCorkle Ave., SE, Charleston, WV
25304, under the direction of the Publication Committee. The views expressed in the Journal are those of the individual authors and do not necessarily
reflect the policies or opinions of the Journal’s editor, associate editors, the WVSMA and affiliate organizations and their staff.
WVSMA Info: PO Box 4106, Charleston, WV 25364
1-800-257-4747 or 304-925-0342
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President’s Message
Generous Light
A sleepless night or early morning awakening is gifted by nature with an encounter of a new dawn.
John O’Donohue’s beginning paragraph in his book “Anam Cara”—describes it so
well and is worth repeating here to share—Thus— LIGHT IS GENEROUS
“If you have ever had occasion
to be out early in the morning
before day breaks, you will have
noticed that the darkest time
of night is immediately before
dawn. The darkness deepens and
becomes more anonymous.
If you had never been to the
world and never known what a day
was, you couldn’t possibly imagine
how the darkness breaks, how the
mystery and color of a new day
arrive. Light is incredibly generous,
but also gentle. When you attend
to the way the dawn comes, you
learn how light can coax the dark.
The first fingers of light appear on
the horizon, and ever so deftly and
gradually, they pull the mantle of
darkness away from the world.”
Quietly before you is the mystery
of a new dawn, the new day.
A new day— in my experience
brings an epiphany—In a perfect
world—life is smooth and
delightful, money grows on trees
and no one we love ever dies.
In a real world, socks don’t
match, we don’t agree, we never
have enough money, often we are
caught off guard and when we
least expect it—things change.
NB—For more emphasis read this
article with background music—If
you feel the Health System Reform
is apocalyptic—play Giuseppe
Verdi’s—La Forza Del Destino.
If you feel Health System Reform
is utopian—use as background
music the duet of Tabisha and
Ko-Ko from the Mikado. “There is
beauty in the bellow of the blast”.
After 14 months of being
marinated with debates, twists
and turns, on health system
reform, President Obama on
March 23, 2010 signed into law
“The Patient Protection and
Affordable Care Act (H.R. 3590).
This health system reform
legislation gives new direction and
will dramatically change the nation’s
health care system—extending
coverage to an estimated 32 million
Americans while raising costs and
reduction in services for millions
of others. The individuals who
will gain the most are low-income
people who do not receive health
insurance from an employer….
just about everyone else loses, says
Dr. John Goodman, President and
CEO of the self-described National
Center on Policy Analysis.
Advocates of the new law,
naturally have a different view.
They argue that winners include
anyone with a pre-existing condition,
recent college graduates who
cannot get coverage through their
parents, small businesses who will
have access to insurance pools
and doctors who will get paid for
seeing uninsured patients they were
treating for free. What do doctors
stand to gain or lose in all of this?
What Do Doctors Stand to
Gain Or Lose In All Of This
Although the currently uninsured
population clearly benefits, the new
legislation brings both positives
and negatives to doctors.
The key areas are new
Medicaid patients at Medicare
reimbursement rates, potential
new business opportunities for
primary care, funding issues and
controlling expenses, negative
issues over lack of tort reform,
continued chaos with Medicare
reimbursement rates and absence
of incentive for prevention efforts.
About 16 million Americans will
be added to the Medicaid program. In
West Virginia one in three residents
are without insurance and this
equates to 300,000 West Virginians.
Some physicians view this as
a boon to their practice as they
anticipate new patients at a fairly
attractive reimbursement rate. Still
many physicians have no interest in
this part of new Medicaid patients.
West Virginia Medical Journal
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Pundits talk of upward to 60%
of physicians will refuse to care for
these new patients. Throughout the
country some doctors are limiting
their percentage of Medicare patients
or even eliminating them entirely.
Some doctors will avoid the new
Medicaid patients as they claim
dealing with government insurance
programs is a snarled tangle of
onerous and frustrating paperwork.
New Business Opportunities
for Primary Care?
The roster of newly insured patients
could turn into a flood or it could
turn out to be less than anticipated.
But in many cases, it could present
practice opportunities for doctors.
• New business models may
attract primary care physicians willing
to hire more PAs and NPs in order to
see patients. Doctors who expand in
this way could increase their volume
of patients while containing costs
by using healthcare providers with
salaries less than that of physicians.
• Inner-city practices may spring
up. Some doctors may be interested in
setting up practices in inner cities or
areas where patients are now served
by clinics or training hospitals.
There might be more demand in
inner-city areas or indigent areas
where the Medicaid population is
greater. Many of those distressed
areas probably have a paucity
of physicians to begin with.
• Payment instead of unpaid
charity care. Hospitals currently
lose millions of dollars annually on
charity care for patients who show
up in the emergency room without
insurance and who do not pay their
bills. Physicians also do not get
paid—or receive a pittance—for
charity care. If patients going to
hospital emergency rooms have
insurance—even at Medicare rates—
hospitals and doctors will receive
at least some degree of payment.
• More primary care doctors will
be trained. There are provisions for
increasing the number of primary care
doctors to be available in the future
to care for the additional patients.
However, it’s not a given that all
newly insured patients will opt to
see primary care doctors in office
practices. Most uninsured people
are being seen now, whether it’s
in clinics or hospital emergency
rooms. There are also people
who have the opportunity to see
physicians but don’t access them.
And some patients may not
be diligent at managing their
healthcare or getting screening
tests every year or three years.”
Funding the Plan and
Controlling Expenses
A new tax being levied to fund
health system reform may hit doctors
(and other high earners) harder
than the rest of the population. The
legislation calls for a 3.8% Medicare
Part A (hospital insurance) tax on
unearned income for individuals
making more than $200,000 and for
married couples $250,000. Many
doctors are in that tax bracket. You’ll
pay a tax on your investment capital
gains, and if you sell your house,
you’ll pay a tax on the capital gains.
Paying hefty taxes may lead doctors
to question working nights and extra
hours. When such a large chunk of
income goes to taxes, it becomes
less attractive to take personal time
to bring in more income. Most
Americans do not have the stomach
for the raise in taxes needed to make
healthcare a right and not a privilege.
Ultimately, this will be untenable. The
cost of these entitlement programs
will be astronomical. It sounds good
that insurers have to accept everyone
with preexisting conditions, but
where does the money come from?
Tort Reform Is Overlooked
The inattention to malpractice
reform has two effects:
It fails to lessen the number of
lawsuits brought against doctors
by plaintiffs looking for a quick
jackpot. It also neglects to address
the very real issue of defensive
medicine, which doctors say jacks
up the costs of healthcare.
Jackson Health Care and the Center
for Health Transformation recently
reported that of physicians surveyed
nationally 73% said they practice
some form of defensive medicine.
Physicians order hundreds of exams
every year to document conditions
that don’t exist. Even if they know
that the chance of something being
there might be 1 in 10,000, they will
still order. In this legislation, there
was little bone to discuss tort reform.
Gallup conducted the sixweek, nationwide survey across
all specialties. These physicians
reported that 26% of overall
healthcare costs can be attributed to
the practice of defensive medicine.
Continued Chaos With
Payment Rates
Notably absent was any mention
of fixes to the Sustainable Growth
Rate (SGR), which determines
physician reimbursement. Medicare
Reimbursement cuts –whether or
not made at the full 21.2% When
the SGR was enacted into law in
1997, the plan was that Medicare
payments for physician services
under Part B would be adjusted
annually according to the SGR to keep
spending for these services in line
with growth in the national economy.
Every year, the SGR calculates a
physician payment update based
on a formula that compares target
expenditures to actual expenditures
for previous years. Since 2001, actual
expenditures for physicians services
have exceeded target expenditures
and thus led to a calculated decrease
in the physician payment update in
each subsequent year. Every year
since 2003, Congress has been called
upon to provide temporary legislation
to reverse the projected cuts in
physician reimbursement. Unless
Congress acts to change the SGR
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system an indefinite series of these
stop gap “fixes” will be required to
fend off a major drop in Medicare
reimbursement. Implementing
the SGR would be catastrophic to
our health care delivery system.
Medicare payments currently
cover more than 51 percent of
physicians’ direct practice costs, yet
Medicare payments today are only
1 percent higher than they were in
2001. During that same period, the
costs of a physician running a practice
have increased 22% as measured
by the Medicare Economic Index.
Late Thursday night (4-15-2010)
the House voted 289 to 112 to enact a
bill armed at postponing, yet again,
the reduction in payments mandated
by the sustainable growth rate
formula until June, 2010. The Senate
approved the postponement several
hours earlier by a vote of 59 to 38.
Prevention and Wellness
Many politicians have said
that keeping patients healthy
through prevention education
will be important as far as
keeping healthcare costs low.
But where’s the beef?
The legislation contains no
financial incentives directed at
patients to encourage them to lower
their cholesterol, quit smoking, lose
weight, or in other ways to take
responsibility for their health. At
the moment, responsibility rests
with public education programs
and with physicians who are
supposed to motivate patients.
The patient has little financial
incentive to be a collaborator.
Viewing the rest of the world from
the hill we call home (Conchita’s
Peak), I accept the challenge
and ask our members not to lose
perspective of the significance of
health system reform. Perspective
is the ability to see the world as it
is. Healthy perspective welcomes
new information, and humbly adapt
as yet another angle appears, it
acknowledges the vast void while
appreciating our fast paced private
life; it can see the forest and the trees,
the sun and the stars. Unfortunately
as physicians we have relinquished
our own thinking and instead look
to classifications, schemes, and
algorithms to think for us. We need to
pause to digest the true significance
of HR 3590 and put it in its proper
place. Change is coming and we
need to dress up for its presence.
The 2010 West Virginia Legislative
Session has finally ended. I came
early on dressed up as a Gladiator
rendering my salutations to
our honorable legislators.
The Medical Professional
Liabilities Act of 2003 was left
unscathed, although this is still a
very attractive target. Be prepared
to have this revisited soon from
several fronts—challenges to our
allies in the legislatures including
Senator Jenkins and Senator Stollings,
changing the makeup of the Supreme
Court Justices and challenges to
the unconstitutionality of MPLA.
June 30th will usher out
the demise of the unpopular
healthcare provider tax. Let’s not
be lulled that we will not hear
of this ever when things become
difficult for the State to provide
the added expense of increased
burden of new (300,000) insured,
do not be surprised if this will be
resurrected under a new guise.
The legislature also addressed
the problem of substance abuse and
drug diversion and addiction.
SB 365 – Requiring pharmacies
provide personnel online access to
controlled substances database.
SB 81 – Creating WV Official
Prescription Program Act
SB 362 – Prohibiting providing
false information to obtain
controlled substances prescription.
Scope of practice issues dominated
the legislative session. The fight
between the optometrist and the
medical community on SB 230
garnered the most attention both
locally and at the national level. We
should compliment the campaign
and the tenacity of our West
Virginia Ophthalmology Association
under the aegis of their Legislative
Chairman Stephen Powell.
Although a watered down version
was finally approved after much
discussion and e-mails (300 plus)
sans laser surgery and the use of
the term “Optometric Physician”
The bill presented to the Governor
was described as flawed and
had language inconsistencies.
Letters we have sent to the
Governor underscoring the technical
deficiencies to veto the bill, had
been delivered not once, but twice.
Quietly and without fanfare he
signed it to law on the eleventh hour.
I can tell you that our legislative
leadership and its members, most
especially our own Legislative
Committee Chairman, Austin
Wallace and Lobbyist, Amy Tolliver
have diligently gathered and
disseminated information. Thank
you to the 300 plus e-mails sent to
the legislators in opposition of SB 230
supporting our Ophthalmology
associates. It is WVSMA at its best.
As the full mantle of Health
System Reform envelopes the state,
there will be more challenges by
non-physicians on medical scope
of practice. Invading barbarians
are at the gates—be prepared!
From Conchita’s house on top of
the hill, the light at dawn is magical. I
now leave you with the Spirit of Zen.
“Freedom comes through complete
acceptance of reality. Those who
wish to keep their illusions do not
move at all. Those who fear them run
backwards into greater illusion, while
those who conquer them walk on.”
Let’s change. Git!
Carlos C. Jimenez, MD
WVSMA President
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What’s Good for Them Is Good for You.
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Our Editor Speaks
I Couldn’t Have Said It Better Myself!
Reprinted with the permission of the CHARLESTON DAILY MAIL
Published: Thursday, April 15, 2010
On Monday of last week,
a tremendous explosion tore
through the Upper Big Branch
Mine in Raleigh County. Two men
were hospitalized, and 29 miners
could not be accounted for.
The news was very bad.
Emergency services, mine rescue
specialists and mine rescue teams
streamed to the site from all over
the state. Not long after, reporters
and cameramen from all over the
nation converged near the mine.
The intense media scrutiny added
to the terrible pressures the miners’
families faced as they waited for
information. The presence of so many
news teams also tested members
of the community, who graciously
rallied not only to support the
miners’ families but also to help
those in the media do their jobs.
A very bad time brought
out very fine behavior.
Then came the lawyers.
This past Tuesday, some of the
miners’ obituaries began appearing
in the paper. A full-page expression
of sympathy from the National
Mining Association also appeared.
So did an ad from the
Underwood Law Offices,
headquartered in Huntington.
“As the families of the victims
of the Massey mine disaster cope
with the loss of their loved ones,
they are also coming to grips with
the fact that their tragic loss didn’t
have to happen,” it began.
“You Need Real Experts On
Your Side,” it said. “One of the
keys is to start right now.”
“Call the Underwood Law
Offices Now to Find Out More.”
The ad concluded: “Call us now.”
Mark Underwood, the
firm’s principal shareholder,
explained to Daily Mail Business
Editor George Hohmann:
“Our thought process was, our
thoughts and prayers are going out to
the miners’ families. We felt we had
to do something. We were so touched
by what is going on down there.”
Like troll for business? As
Hohmann explained, law firms
typically receive a third of the amount
awarded by courts in such cases.
Charleston lawyer Harry Bell took
a different tack. He told Hohmann
he couldn’t bring himself “to run
TV or newspaper ads before all of
the funerals,” and went on to offer
some free advice to the families:
There’s a two-year statute of
limitations for filing a suit alleging
wrongful death. There is no need for
families to rush to make decisions.
Good to know.
MJ_MayJune_10.indd8
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Guest Editorial
Eye Surgery is for Eye Surgeons
An open letter to the public
REPRINTED WITH PERMISSION
OF THE SUNDAY GAZETTE-MAIL
By STEPHEN R. POWELL, M.D.
Some of you may have seen
the recent newspaper, radio and
TV coverage of the “dispute”
between optometrists and medical
organizations at the Capitol.
The question for you is simple
as well: Do you want someone
who is not a licensed medical
doctor and surgeon performing
surgery on your eyes?
That’s the issue. That’s what
this disagreement is all about.
That’s what’s being considered
in legislation (SB230).
Ophthalmologists across the state
receive referrals from optometrists
every day. The two professions
work well together to provide
a comprehensive range of care.
Optometrists earn a bachelor’s
degree and then a doctorate in
optometry. They examine eyes,
prescribe glasses and have good
general training. Optometrists refer
patients to ophthalmologists for
complicated medical procedures,
surgeries and treatments.
Medical doctors trained in the
practice of medicine and surgery earn
a bachelor’s degree and a doctorate,
too. But then these physicians go
on to internship and residency for
another four years or 12,000 hours
of supervised medical and surgical
training. This includes the study of
the human body and surgery, and
how the body reacts to different
medications and diseases, many
of which affect the eyes. Then, and
only then, have ophthalmologists
earned the privilege of performing
medical procedures on your eyes.
The bill now moving through
the Legislature has certainly taken a
twisted route. It started out dealing
with rules for the Board of Optometry
and - at least as of this writing - will
permit optometrists to perform some
eyelid surgeries, laser surgery in the
eye, do injections around the eye,
and order laboratory tests. These are
not permitted in West Virginia now,
and laser surgeries by optometrists
are not permitted in 49 states.
So, what if something goes
wrong? Are optometrists trained
to prescribe medications that may
affect blood pressure, or interfere
with diabetes treatment?
Are optometrists trained to
know how and when to adjust
medications for patients with
impaired kidney function? Have
optometrists performed hundreds
of surgeries under the watchful
eye of experienced surgeons before
being granted the privilege to cut
on patients without supervision?
If laser surgery by optometrists
is such a good idea, why did the
Veterans Administration, after
a five-year study, adopt a policy
that only physicians trained in the
practice of medicine and surgery of
the eye can perform laser surgery on
our nation’s veterans and prohibit
optometrists from doing so?
If this is such a good idea, why
does the state chapter of AARP
oppose it? And why do 20 medical
organizations - including the
West Virginia Board of Medicine,
the Hospital Association and the
Medical Association - oppose it?
Many senators and delegates are
well-intentioned and approachable
and have looked at these issues.
They hear talk from all sides and
are subjected to lots of political
pressure. What we need now is
for the public to tell them patient
safety should come first.
It is the opinion of your
medical doctors and surgeons
that it’s important for your own
patient safety that you contact
your legislators immediately and
ask them to vote against SB230,
the “optometry surgery bill.”
Simply put, it is bad medicine.
Powell is a Morgantown
ophthalmologist and past
president of the West Virginia
Academy of Ophthalmology.
Letters to the Editor and commentary articles may be sent to Angie Lanham, Managing Editor at
PO Box 4106, Charleston, WV 25364 or E-mail to [email protected].
May/June 2010 | Vol. 106 MJ_MayJune_10.indd9
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D. Richard Lough, MD
Michael R. Goins, MD
P. Todd Nichols, MD
G. Stephen Dawson, MD
F. Thomas Sporck, MD, FACS
4/23/20103:10:45PM
Scientific &
Special Articles
A Review of the American Heart Association Revised
12
A Young Male with Sudden Onset Left-Sided Weakness
16
Free Muscle Flap Reconstructions Using Interpositional
at a Rural Tertiary Care Center
19
Successful Pregnancy Following Conservative Surgical
24
Geographic and Temporal Comparisons of ATV Deaths
26
From Medical Student to Board Certified Physician
30
May/June 2010 | Vol. 106 11
4/23/20103:10:45PM
Scientific Article |
A Review of the American Heart Association Revised
Nasira Roidad, MD
Internal Medicine/Pediatrics Resident
Larry Rhodes, MD
Chief, Section of Pediatric Cardiology
Brad Warden, MD
Assistant Professor Department
of Cardiology
All of WVU Morgantown
Introduction
In our careers as physicians, it
is not often that we experience a
significant change in the therapies
or preventive measures for diseases
we learned in medical school and
residency training. Several examples
of these include the routine use of
screening colonoscopy for colon
cancer, the use of ICDs for patients
with low ejection fractions, and the
development of a vaccine for certain
types of human papillomavirus
for cervical cancer prevention.
In April 2007, the American
Heart Association published revised
recommendations for the guidelines
for infective endocarditis (IE)
prophylaxis. One may think that
this revision does not impact clinical
practice to the same effect as the
examples listed above. However,
for over 50 years, physicians
and patients have closely abided
by the prophylactic measures
previously recommended for a
frightening condition, and now
those recommendations have been
modified. Although physicians
may find this transition to a more
simplified approach to prophylactic
measures appealing, patients
may be more reluctant to accept
this perspective. This difficulty in
acceptance is partly the consequence
of our impact as physicians. For
the last half-century, we have
emphasized to our patients the
importance of antibiotic prophylaxis
prior to dental procedures in order to
prevent the rare, but life-threatening
infective endocarditis. We gave
them cards to put in their wallets
indicating their need for antibiotics
prior to procedures. After these
interventions, it is understandable
that a patient may find it difficult to
do away with this ritual and accept
the risk we present to them. In
order to understand the progression
of this change in preventive
medicine, we need to review the
background and development of
guidelines through the years.
Background
The earliest report of endocarditis
was in 1554 in the book Medicini by
Jean François Fernel. After several
hundred years of theory development
and research by scientists around
the world, the American Heart
Association (AHA) published the
first document recommending
prophylaxis against bacterial
endocarditis. This historic year
was 1955. What was the rationale
for prophylaxis? Endocarditis
generally follows bacteremia. If
bacteremia is caused by certain
procedures, then antibiotics should
be given to those patients with
predisposing heart conditions prior
to those procedures.12 The first
recommendations for prophylaxis
were for patients with rheumatic
or congenital heart disease
undergoing dental procedures or oral
manipulation. The drug of choice
was penicillin given prior to the
procedure and for the following five
days. This was also suggested for
patients having GI or GU surgery.4
Over the last 50 years,
changes have been made to
these recommendations most
often involving the duration of
prophylactic therapy. Penicillin/
amoxicillin remains the ideal
antibiotic for those without
sensitivity. In 1997, the AHA
provided a more detailed set of
recommendations dividing the types
of underlying heart diseases into high
risk, moderate risk and negligible risk
categories as well as specifying which
procedures were high, intermediate,
or low risk. They used these
divisions and the planned procedure
(dental, respiratory, GI or GU) to
determine the specific prophylactic
recommendations. Included in this
recommendation was also limiting
the administration of antibiotics to
simply prior to the procedure.2
Present Day
In May of 2007, the AHA
reviewed the principles behind the
recommendation for IE prophylaxis
and the literature to support them.
According to their official report,
there were five basic principles for
formulation of their guidelines. They
included: 1) IE is uncommon, but
life threatening and prevention is
preferable to treatment. 2) There are
certain underlying cardiac diseases
that predispose to IE. 3) The bacteria
known to cause IE occurs commonly
in association with invasive dental,
GI, or GU tract procedures.
4) Antimicrobial prophylaxis was
proven to be effective for prevention
of experimental IE in animals. 5)
Antimicrobial prophylaxis was
thought to be effective in humans
for prevention of IE associated
with dental, GI, or GU procedures.1
They felt that the first four of
these principles held true today;
12 West Virginia Medical Journal
4/23/20103:10:45PM
| Scientific Article
however, there was no clear scientific
evidence to support the fifth.
Discussion
When trying to understand the
risk of bacteremia that may lead
to IE, they found that the transient
bacteremia exposure during a
brief dental procedure was a much
lower risk to patients than the more
frequent bacteria exposure we
experience on a daily basis from
routine activities. A study from
Roberts, estimates that brushing
teeth two times per day for one year
had a 154,000 times greater risk of
exposure to bacteremia than that
resulting from tooth extraction.7
Guntherwoth quantifies the time of
exposure risk by pointing out that
there is a cumulative exposure of
5370 minutes of bacteremia over
a one month period in dentulous
patients, resulting from random
bacteremia from daily measures
(such as chewing, tooth brushing,
flossing) compared with a 6-20
minute duration associated with
tooth extraction8. Durack points
out that the bacteremia related
to procedures is short-lived. The
detection of positive blood cultures
is highest 30 seconds after a tooth
extraction and most episodes of
bacteremia associated with dental
procedures last less than 10 minutes.
If patients develop symptoms of
endocarditis following a procedure,
the interval of symptom onset
should be short, within 2 weeks.
Those patients who have a longer
incubation period probably did not
develop endocarditis as a direct
result of the procedure. Nonetheless,
the true upper limit of incubation
period is not known for certain.12
There are several case control
studies looking at the efficacy of
prophylactic antibiotics; however,
they provide conflicting results. One
study found a protective efficacy of
91% for prophylaxis; however, this
study included only 8 case patients
over a period of 6 years. This may
have made the time relation between
procedure and diagnosis difficult to
assess. In addition, the prophylaxis
was defined by patient’s recall,
not by evidence that an antibiotic
regimen recommended by the
AHA was given.10,12 A second case
control study in the Netherlands
concluded that prophylaxis was
probably not effective and even
if it was, it would do little to
decrease the total number of cases
of endocarditis.3,12 Furthermore, one
must take into account the associated
risk of antibiotic administration
including hypersensitivity reactions
and other adverse events. There is
also possible occurrence of drugresistant organisms.3 There are no
randomized controlled trials to prove
the effectiveness of endocarditis
prophylaxis. To perform this
kind of trial would require large
numbers. It also may be considered
unethical because antibiotic
prophylaxis, though not validated
by strong scientific evidence, is
regarded as standard of care.12
The AHA presented this research
in its guidelines to support the
change in their recommendations.
They shifted from focusing
on prophylactic therapy for
those patients with the highest
predisposition to the acquisition of
endocarditis to those with the highest
risk of adverse outcome from IE.
Table 1 reviews the cardiac conditions
in which prophylaxis continues to
be recommended. They include
prosthetic cardiac valves, previous
IE, certain congenital heart disease
conditions, and cardiac transplant
patients with valvulopathy.
Conditions excluded from these
recommendations include aortic
stenosis or regurgitation, mitral valve
prolapse, ASD, VSD, and several
others. Table 2 explains the dental
procedures for which prophylaxis
is reasonable. The medical regimens
are included in Table 3.1
In regards to other procedures,
the AHA states that antibiotic
prophylaxis is reasonable for
procedures on the respiratory tract
or infected skin, skin structures or
musculoskeletal tissue for patients
with those underlying cardiac
conditions listed in Table 3 as
these are patients with the highest
risk of adverse outcome from IE.
Table 1. Cardiac Conditions Associated With the Highest Risk of
Adverse Outcome From Endocarditis for Which Prophylaxis With Dental
Procedures Is Reasonable1
1. Prosthetic cardiac valve
2. Previous IE
3. Congenital heart disease (CHD)*
-Unrepaired cyanotic CHD, including palliative shunts and conduits
-Completely repaired congenital heart defect with prosthetic material or
device, whether placed by surgery or by catheter intervention, during
the first 6 months after the procedure†
-Repaired CHD with residual defects at the site or adjacent to the site of
a prosthetic patch or prosthetic device (which inhibit endothelialization)
4. Cardiac transplantation recipients who develop cardiac valvulopathy
*Except for the conditions listed, antibiotic prophylaxis is no longer recommended for any
other form of CHD.
†Prophylaxis is recommended because endothelialization of prosthetic material occurs within
6 months after the procedure.
May/June 2010 | Vol. 106 13
4/23/20103:10:46PM
Table 2. Dental Procedures for
Which Endocarditis Prophylaxis Is
Reasonable for Patients in Table 11
All dental procedures that involve
manipulation of gingival tissue or
the periapical region of teeth or
perforation of the oral mucosa
The following procedures and
events do not need prophylaxis:
routine anesthetic injections
through noninfected tissue, taking
dental radiographs, placement
of removable prosthodontic
or orthodontic appliances,
adjustment of orthodontic
appliances, placement of
orthodontic brackets, shedding
of deciduous teeth, and bleeding
from trauma to the lips or oral
mucosa.
There has been limited research in
the association of GI and GU tract
procedures and IE. There are few
cases reported of IE temporally
associated with a GI or GU tract
procedures, and there are no studies
to show a clear link between the
two. There has also been an increase
in antimicrobial-resistant strains of
enterococci. Therefore, antibiotic
prophylaxis solely to prevent IE is no
longer recommended by the AHA
for GI or GU tract procedures.1
Conclusion
So, what is the take home message
from the AHA’s latest revision?
For those patients who previously
required prophylaxis as well as those
who continue to need it based on
the new guidelines, the emphasis
of prevention should be on good
daily oral hygiene. The important
preventive measures include
brushing teeth, flossing and seeing
a dentist for regular check-ups.13
These are the points that should be
discussed with patients. For primary
care providers, these are already
part of routine health maintenance
concerns. One should continue to
offer prophylaxis to those patients
at highest risk of adverse outcome
(see Table 1). As discussed above,
one may find that both adult patients
and the parents of pediatric patients
have difficulty in discontinuing the
prophylactic antibiotic if they no
longer fit the criteria. In this case,
one has to consider the risk versus
benefit of taking an antibiotic prior to
procedures. Most often, this decision
will be made on an individual basis.
One may consider reviewing the
article’s main points with the patient
and use a shared decision making
process to determine what is best for
that patient. In looking to the future,
the importance of prophylaxis for IE
remains, as does the need for further
research and prospective trials.
There shall continue to be ongoing
evolution of this issue as is the case in
many aspects of medicine; however,
the unchanging and common
thread among all practitioners
continues to be doing what is best
for patients and society as a whole,
especially in matters of the heart.
References
1. Wilson W, et al. Prevention of infective
endocarditis: guidelines from the American
Heart Association: a guideline from the
American Heart Association Rheumatic
Fever, Endocarditis, and Kawasaki
Disease Committee, Council on
Cardiovascular Disease in the Young, and
the Council on Clinical Cardiology, Council
on Cardiovascular Surgery and
Anesthesia, and the Quality of Care and
Outcomes Research Interdisciplinary
Working Group. Circulation. 2007 Oct
9;116(15):1736-54. Epub 2007 Apr 19.
2. Dajani AS, et al. Prevention of bacterial
endocarditis: recommendations by the
American Heart Association. JAMA.
1997;277:1794 –1801.
3. Strom BL, Abrutyn E, Berlin JA, Kinman
JL, Feldman RS, Stolley PD, Levison ME,
Table 3. Regimens for a Dental Procedure.1
Situation
Agent
Adults
Children
Oral
Amoxicillin
2 g
50 mg/kg
Unable to take oral
Ampicillin
OR
Cefazolin or
Ceftriaxone
2 g IM or IV
1 g IM or IV
50 mg/kg IM or IV
50 mg/kg IM or IV
Allergic to penicillin
Cephalexin*†
OR Clindamycin
OR
Azithromycin
or clarithromycin
2g
600 mg
500 mg
50 mg/kg
20 mg/kg
15 mg/kg
Allergic to penicillins
or ampicillin and
unable to take oral
medication
Cefazoilin or
ceftriaxone † Clindamycin
1g IM or IV
600 mg IM OR IV
50 mg/kg IM or IV
20mg/kg IM or IV
* Or other first or second generation oral cephalosporin in equivalent adult or pediatric dosage
† Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema,
or urticaria with penicillins or ampicillin.
4/23/20103:10:46PM
Korzeniowski OM, Kaye D. Dental and
cardiac risk factors for infective
endocarditis: a population-based, casecontrol study. Ann Intern Med.
1998;129:761–769.
4. Jones TD, Baumgartner L, Bellows MT,
Breese BB, Kuttner AG, McCarty M,
Rammelkamp CH (Committee on
Prevention of Rheumatic Fever and
Bacterial Endocarditis, American Heart
Association). Prevention of rheumatic fever
and bacterial endocarditis through control
of streptococcal infections. Circulation.
1955;11:317–320.
5. Committee on Prevention of Rheumatic
Fever and Bacterial Endocarditis,
American Heart Association. Prevention of
rheumatic fever and bacterial endocarditis
through control of streptococcal infections.
Circulation. 1960;21:151–155.
6. Lockhart PB, Brennan MT, Kent ML,
Norton HJ, Weinrib DA. Impact of
amoxicillin prophylaxis on the incidence,
nature, and duration of bacteremia in
children after intubation and dental
procedures. Circulation. 2004;109:
2878 –2884.
7. Roberts GJ. Dentists are innocent!
“Everyday” bacteremia is the real culprit:
a review and assessment of the evidence
that dental surgical procedures are a
principal cause of bacterial endocarditis
in children. Pediatr Cardiol.
1999;20:317–325.
8. Guntheroth WG. How important are dental
procedures as a cause of infective
endocarditis? Am J Cardiol. 1984;54:
797– 801.
9. Imperiale TF, Horwitz RI. Does prophylaxis
prevent postdental infective endocarditis?
A controlled evaluation of protective
efficacy. Am J Med. 1990;88:131–136.
10. van der Meer, JT. Prophylaxis of
endocarditis. Neth J Med. 2002
Dec;60(11):423-7. Review.
11. Beynon RP, Bahl VK, Prendergast, BD.
Infective Endocarditis. BMJ. 2006 Aug
12;333(7563):334-9.
12. Durack, D. Prevention of Infective
Endocarditis. NEJM. 1995, Jan 5. 332:
38-42.
13. Prendergast, BD. The changing face of
infective endocarditis. Heart
2006;92;879-885. originally published
online 10 Oct 2005.
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May/June 2010 | Vol. 106 15
4/23/20103:10:48PM
A Young Male with Sudden Onset Left-Sided Weakness
Sharjeel Ahmad, MD
Fellow, Section of Infectious Diseases
Department of Medicine
WVU, Morgantown
Melanie Fisher, MD
Professor, Section of Infectious Diseases
Department of Medicine
WVU, Morgantown
Introduction
Neurosyphilis is the infection
of the central nervous system by
Treponema pallidum subspecies
pallidum, which can occur any time
after the initial infection. We present
a case of neurosyphilis as a pontine
stroke in an otherwise asymptomatic
immunocompetent male.
Case Report
A 38-year-old Caucasian,
previously healthy male developed
sudden onset left-sided numbness,
weakness, slurred speech and
left facial droop, with worsening
difficulty walking over 24 hours.
The patient did not smoke or use
cocaine. He sought care at the local
emergency room. Initial work-up
with CT and MRI did not reveal
any acute intracranial process. He
was subsequently transferred to
a tertiary care hospital for further
evaluation and management.
On initial evaluation, patient
was in no apparent distress. Blood
pressure (BP) was 144/72, Pulse 76
and respiratory rate 16. Physical
examination was significant for
left eyelid and facial droop with
decreased sensation on the left side
of the face. Power and reflexes were
decreased in the left proximal and
distal upper and lower extremities.
The remainder of the physical
exam was within normal limits.
The patient was living with
his current male partner for the
last six months and both of them
denied history of body rash,
injection drug use, genital ulcers or
sexually transmitted infections.
An HIV antibody test was
negative. MRI brain showed small
right-sided pontine infarct and
white matter abnormalities in right
frontal lobe (Figures 1 and 2) . A
lumbar puncture was performed. It
showed CSF glucose of 37 mg/dL,
protein of 77 mg/dL, RBC 0/µL,
WBC 7/ µL with a negative HSV1,2 DNA PCR, Gram and India ink
stain. Cultures of the CSF fluid did
not show growth of any organism.
A hyper-coaguable state workup was negative. Intracranial MRA
showed apparent narrowing of the
A1 segment of the right anterior
cerebral artery (Figure 3), while
extracranial MRA showed slight
narrowing of the left vertebral
artery terminus at the confluence
of the vertebral arteries (Figure 4).
Patient’s CSF VDRL was positive,
with a positive serum Treponema
pallidum particle agglutination
Meningovascular syphilis
occurs due to involvement of blood
vessels in the subarachnoid space
resulting in arteritis, leading to
thrombosis, infarction and ischemia.
The middle cerebral artery is the
most commonly affected part of the
circulation, although involvement
of other blood vessels such as
cerebellar arteries1 is possible.
In recent years, men who have sex
with men (MSM) have accounted for
an increasing number of estimated
syphilis cases in the United States.2
In the current era, it is estimated that
64% of syphilis cases in the United
States occur in the MSM population.3
These infections are characterized by
high rates of HIV co-infection and
high risk sexual behavior.4-8 This case
Figure 1.
Figure 2.
MRI Brain, Axial : Diffuse weighted
imaging of pons 1.7 x 0.8 cm area of
high signal (white arrow head) on
diffusion-weighted imaging compatible
with a small area of infarct.
assay (TPPA). Given the signs
and symptoms, radiological and
laboratory findings, he was treated
as a case of neurosyphilis.
Discussion
MRI Brain, Axial: FLAIR imaging of
cerebral hemispheres. A punctate focus
of increased signal within the subcortical
white matter of the left frontal lobe, which is
non-specific in nature (white arrow head).
4/23/20103:10:48PM
highlights syphilis as an important
cause of stroke in otherwise healthy
asymptomatic MSM patients.
Clinical suspicion and spinal fluid
examination are keys to the diagnosis
of neurosyphilis. Confirmation
of initial infection can be done
by use of serum non-treponemal
(VDRL and RPR) and treponemal
(FTA-ABS, TPPA) tests. The nontreponemal tests may be nonreactive
in late neurosyphilis, hence serum
treponemal testing should be
performed if there is a clinical
suspicion for late neurosyphilis.
The CSF-VDRL, considered as
the gold standard for diagnosis of
neurosyphilis, can be falsely negative
in 22-69% of these patients9. CSF
FTA-ABS is sensitive but not specific
and is recommended by some for
use in clinically suspicious patients
with lymphocytic CSF pleocytosis
and a nonreactive CSF-VDRL.10
For neurosyphilis, CDC STD
treatment guidelines recommend
a 10-14 day course of aqueous
crystalline penicillin G 18–24
million units per day, administered
as 3–4 million units IV every 4
hours or continuous infusion.11
Some specialists recommend
benzathine penicillin 2.4 million
units IM once per week for three
weeks after completion of the two
weeks treatment. This is to be
followed by serial CSF examination
every 6 months to monitor white
cell count and VDRL titers after
therapy. Retreatment with a full
course may be required based
on monitoring of these values.
Our patient was treated with
intravenous Penicillin G 4 million
units every 4 hours, followed by
three doses of benzathine penicillin
2.4 million units IM once per week.
He was discharged to a rehabilitation
facility in his hometown, with
follow-up arranged for serial
lumbar puncture every 4-6 months
to monitor CSF white blood cell
count, VDRL titers. The patient
made a partial recovery and was
able to walk using a cane 1 year
after completion of treatment.
References
1. Umashankar G, Gupta V, Harik SI. Acute
bilateral inferior cerebellar infarction in a
patient with neurosyphilis. Arch Neurol.
2004;61:953-956.
2. Heffelfinger JD, Swint EB, Berman SM,
Weinstock HS. Trends in primary and
secondary syphilis among men who have
sex with men in the United States. Am J
Public Health 2007;97: 1076-1083.
3. Beltrami JF, Weinstock H.S. Primary and
secondary syphilis among men who have
sex with men in the United States, 2006.
In: program and abstracts of the 17th
Biennial meeting of the ISSTDR, Seattle,
WA, July 29-August 1, 2007 [abstract
O‑069].
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May/June 2010 | Vol. 106 17
4/23/20103:10:48PM
4. Centers for Disease Control and
Prevention. Resurgent bacterial sexually
transmitted disease among men who have
sex with men – King County, Washington,
1997–1999. MMWR 1999;48:773-777.
Prevention. Outbreak of syphilis among
men who have sex with men – Southern
California, 2000. MMWR
2001;50(7):117‑20.
Prevention. Primary and secondary
syphilis among men who have sex with
men – New York City, 2001. MMWR
2002;51:853-6.
7. Chen SY, Gibson S, Katz MH, Klausner
JD, Dilley JW, Schwarcz SK, Kellogg TA,
McFarland W. Continuing increases in
sexual risk behavior and sexually
transmitted diseases among men who
have sex with men: San Francisco,
California, 1999–2001 [Letter]. Am J Public
Health 2002; 92:1387-8.
8. D’Souza G, Lee JH, Paffel JM. Outbreak of
syphilis among men who have sex with
men in Houston, Texas. Sexually
Transmitted Diseases 2003;30:872-3
9. Hart, G. Syphilis tests in diagnostic and
therapeutic decision making. Ann Intern
Med 1986; 104:368-376.
10. Jaffe, HW, Larsen, SA, Peters, M, et al.
Tests for treponemal antibody in CSF. Arch
Intern Med 1978; 138:252-255.
11. Workowski, KA, Berman, SM. Sexually
transmitted diseases treatment guidelines,
2006. MMWR Recomm Rep 2006;
55(RR11): 27-28.
Figures 3 and 4.
MRA image of brain vasculature: Narrowing of the A1 segment of the right anterior cerebral artery (white
arrow head) and of the left vertebral artery at the confluence of vertebral arteries (black arrow heads).
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4/23/20103:10:49PM
Free Muscle Flap Reconstructions Using Interpositional
at a Rural Tertiary Care Center
Matthew S. Loos, MD
Department of Surgery
WVU, Morgantown
Bruce G Freeman MD, PhD
Department of Surgery
WVU, Morgantown
W.Thomas McClellan, MD
Plastic Surgeon
Morgantown, WV
Abstract
Background: The use of free muscle
or myocutaneous flaps is well established
as a means for reconstructing tissue
defects over nearly any part of the body.
This free tissue transfer is based on the
availability of a robust blood supply in the
recipient wound. The reliability of native
blood supplies within the zone of injury is
suspect even in the best of conditions.
There are several causes of flap failure
however; one of the most common is
vascular compromise. Though
refinements in the technique of vascular
anastomosis have lessened the risk, it is
still significant, especially when dealing
with an area of injury at the recipient site.
The mechanisms of scar formation and
healing that occur within the zone of injury
often limit the potential for viable
anastomotic targets. This often leads to
delay in wound coverage and exposes the
patient to all of the risks associated with
having an open wound. Free flap failure
can be devastating for patients, even
leading to the loss of limbs. Therefore, it
is vital that all measures possible to
ensure the survival of the transferred
tissue be employed.
Methods: We will examine
interpositional vein grafts versus local
anastomoses in the context of free tissue
transfer for wound coverage in the
traumatized and reconstructed patient.
We will retrospectively review the case
histories of free tissue transfers
preformed at West Virginia University
Hospital over a 5-year period (20012006). We will examine data including the
demographics of our patient population,
type and locations of the free flaps, length
of stay in the hospital, time interval
between injury and repair, and the
success and failure rate.
Results: The overall success rate
was 38 out of 45 or 84%. Success was
defined as a healthy flap and preservation
of the limb and/or successful wound
coverage at time of discharge. Flap
success was present in 18 of 23 (78%) of
the vein interposition grafts, and flap failure
occurred in 5 (22%). In patients with local
anastomoses, 20 out of 22 flaps survived
(91%) with 2 failures (9%).
Goals: We will demonstrate that the
use of interpositional vein grafts for free
tissue transfer is a viable option in the
wound coverage. We will demonstrate
that this is especially true in the patient
population that exists in rural America.
Introduction
The primary goal in any patient is
to return him or her to as normal a
life as possible after repair of injury.
The ability to cover tissue defects
has greatly helped to fulfill this goal.
The use of muscle, myocutaneous,
fasciocutaneous, or bowel free flaps
is well established as a means for
reconstructing tissue defects over
nearly any part of the body. These
free tissue transfers are based on
the availability of a robust blood
supply in the recipient wound.
The reliability of native blood
supply within the zone of injury is
suspect even in this era of improved
diagnosis and increased experience
with free tissue transfers.1 Despite
this, free flaps remain one of the
most delicate surgeries performed.
The causes of flap failure are
varied; however, one of the most
common is vascular compromise.
Refinements in the technique of
vascular anastomosis have lessened
but not abolished the risk. The
processes of scar formation and
healing that occur within the zone
of injury often limit the potential
for viable anastomotic targets,2,3,4,5,6
leading to delay in wound coverage
and exposure of the patient to
potential complications of an open
wound. Free flap failure can be
devastating, even leading to the
loss of limb. Therefore, all measures
possible to ensure the survival of the
transferred tissue must be employed.
Numerous authors have sought
to elucidate factors responsible
for success or failure. Our study
seeks to add to this discussion
by evaluating the experience in
a tertiary care center serving a
predominantly rural population.
Patients and Methods
All consecutive free tissue
transfers were examined for a 5-year
period (July 2001 to April 2006) at
West Virginia University Hospital.
They represent the work of the two
plastic and reconstructive surgeons
at this rural tertiary care institution.
For this discussion, the definition
of traumatized tissue has been
extended to include tissue that has
been exposed to radiation therapy
and chronic infection, as these are
common in our population. Clinical
parameters were retrospectively
reviewed from patient’s charts,
including demographics, use of
interpositional vein grafts or local
anastomoses, timing, complications,
length of stay, and perioperative
nutritional status. The rates of
success of vein grafts and local
anastomoses were compared.
Results
During the 5-year period, 42
patients required free tissue transfer.
There were 31 males and 11 females
and their mean age was 43 (range
May/June 2010 | Vol. 106 19
4/23/20103:10:49PM
Table 1.
Interpositional Vein Grafts (n=23)
Local Anastomosis (n=22)
19:3 (one male required two)
12:10
Age (mean)
41.8 years
42.2
43
LOS (days)
18.3
15.6
18.7
Albumin (mean range)
2.11-2.97 g per dL
2.1-3.26 g per dL
2.06-3.11 g per dL
Prealbumin (mean range)
9.7-19.2 mg per dL
8.6-17.4 mg per dL
8.8-18.2 mg per dL
Sex, M:F
14-73). The length of stay averaged
18.7 days (range 6 to 80 days).
Those with vein interposition grafts
averaged 18.3 days while those
with local anastomoses averaged
15.6 days. Among all of the patients
requiring free flaps, the average
albumin in the perioperative period
ranged from 2.06 to 3.11 g per dL
and average prealbumin ranged
from 8.8 to 18.2 mg per dL. (Table 1)
Most cases were the result of
trauma (motor vehicle accidents,
falls, crush injuries, etc.). Cancer, and
chronic wound infections also were
present. We only had one penetrating
injury, a self-inflicted gunshot wound
to the face, during this time. (Table
2) Most tissue defects were found
on the lower extremities (25 out of
42 or 59%). Upper extremity defects
5% (2 of 42), breast defects 12% (5
of 42), and head and neck 24% (10
Overall
of 42) complete the distribution of
defects. Loop grafts were used 23
times in 22 patients, (19 males and 3
females). One male, a hemophiliac
who had shot himself in the face,
required two loop grafts to the face.
The native vessels were used 22
times in 22 patients. Two patients
required both an interpositional
vein graft and native anastomosis
to salvage their limbs and both
were finally successful. (Table 3)
4/23/20103:10:51PM
the vascular pedicle. The flap was
then inset and finished with any
skin-grafting that was necessary.
All patients were monitored
in the intensive care unit postoperatively and all were started on
a Dextran-40 infusion (35ml/hour)
for a period of 5 days.15 Regular
post-operative flap checks were
performed on an hourly basis by
the house staff for the first 3 days.
All the arteriovenous loop fistulas
were created using autologous
reversed saphenous veins. The most
common donor tissue used was the
rectus abdominus myocutaneous
flap. Latissimus, free radial forearm,
jejunal, and scapula flaps were also
employed however. (Table 4)
The overall success rate was
38 out of 45 or 84%. Success was
defined as a healthy flap and
preservation of the limb and/or
successful wound coverage at time
of discharge. Flap success was
present in 18 of 23 flaps, or 78% of
the vein interposition grafts, and
failed in only 5 (22%) patients. In
patients with local anastomoses, 20
out of 22 flaps survived (91%) with 2
failures (9%). Complications in these
patients overall included venous
congestion, thrombosis, infection,
bleeding, and in some, eventual
flap failure. In the patients with
interpositional vein grafts, infection
and thrombus were most common.
In those with the local anastomoses,
venous congestion and thrombus
were seen most often. (Table 5)
Table 2.
Interpositional Vein Grafts (%)
Local Anastomosis (%)
Trauma
14 (61%)
11 (50%)
Cancer
5 (22%)
10 (45%)
Infection
4 (17%)
1 (5%)
23 (100%)
22 (100%)
Total
Table 3.
Interpositional
Vein Grafts (%)
Local
Anastomosis
(%)
Total (%)
Lower Extremity
16 (59%)
11 (41%)
27 (100%)
Head and Neck
6 (60%)
4 (40%)
10 (100%)
Breast
0
5 (100%)
5 (100%)
Upper Extremity
0
2 (100%)
2 (100%)
Those patients requiring a vein
interposition graft for their free flap
underwent a three-team approach.
First, one of two vascular surgeons
harvested and inset the autologous
vein as an arteriovenous loop fistula.
Next, two plastic surgery teams
would work to harvest the donor flap
and prepare the recipient wound.
The arteriovenous loop fistula would
be divided after the donor flap was
explanted and passed to the receiving
team. While the flap was being reimplanted, the harvest team would
close the donor defect. The arterial
anastomosis was created first in
typical end-to-end fashion. The flap
was allowed to perfuse for a brief
period of time, usually 20 minutes,
before the venous anastomosis was
completed, again in end-to-end
fashion. An implantable Doppler
was placed on the venous limb of
the vascular pedicle in nearly all
cases. The body of the flap was then
inset and any skin grafting that
was necessary was completed.
Those patients receiving local
anastomoses underwent surgery
utilizing a two-team approach with
just the plastic surgeons. Donor
flaps were dissected out in standard
fashion and the local vessels prepared
for an end-to-side anastomosis.
These patients too, had a Doppler
implanted on the venous limb of
Table 4.
Rectus Abdominus
Latissimus Dorsi
Radial Forearm
Scapula
Jejunum
Lower Extremity
18
7
2
0
0
Head and Neck
4
0
4
1
2
Breast
5
0
0
0
0
Upper Extremity
2
0
0
0
0
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Table 5.
Interpositional Vein Graft
(%)
1 (4%)
Local Anastomosis
(%)
2 (9%)
Thrombus
4 (17%)
2 (9%)
Hemorrhage
3 (13%)
1 (4.5%)
Infection
5 (22%)
1 (4.5%)
Flap Failure
5 (22%)
2 (9%)
Venous Congestion
Discussion
The decision to anastomose a free
flap locally or with the aid of a vein
interposition graft relies heavily on
the type of injury and the timing.3,4,5,6
Much recent work has been aimed
at further defining when it is
appropriate to anastomose free flaps
within the zone of injury.1,4,6,7,11,16 A
decision must be made between the
inherent difficulties of interpositional
vein grafts, with their multiple
anastomoses and length, and
the reliability of the vasculature
within the zone of injury.14 Local
anastomosis has often been preferred
due to the relative ease and speed
of the reconstruction.4 However,
the local changes within the zone
of injury, especially with delay in
presentation, often complicates
the native vasculature so that local
anastomoses are more difficult.4,8,10
In fact, our average length of time
from initial injury to the first plastic
surgery consult is 637 days overall
and 116.4 days when oncologic
cases are not considered. (Table 6)
The reason for the delay in
presentation for definitive tissue
coverage in our population is unclear.
Perhaps most of the delay is due to
the rural nature of our state and its
medically underserved population.
On average, patients who received
a local anastomosis (usually after
an acute trauma) did so within
about 14-19 days after initial plastic
surgery consultation. Certainly, it
is well known that time is of the
essence in the reconstruction of
traumatic injury in the acute setting.
However, it has been our experience
that delays in presentation or the
other internal or external injuries
suffered in this traumatic setting
have required a delay in wound
closure. Kolker et al. has described
successful anastomosis (94%) within
the zone of injury, regardless of the
time frame.4 Stompro and Stevenson
agreed, listing a 91% success rate.9
In fact, Isenberg and Sherman have
discussed their ability to proceed
with free tissue transfer within a
matter of days after an injury.10
They talk of subjectively rating the
local vasculature for “friability,
perivascular scarring, transmural
thickening, and the presence of
perivascular hemorrhage…” and
with these observed criteria, they
could rely on the local vessels
they encountered.10 They have
even reported success rates as
high as 100% with such local
anastomoses.10 However, these
results are exceptional and the
more widely quoted success rates
have been around 90%. This study
certainly supports this latter figure.
Alternatively, those requiring
a vein interposition averaged 754
days from insult to plastic surgery
consultation and an additional
17-19 days for definitive tissue
coverage. Again the delay likely
represents the wide dispersal of
patients and medical facilities
within our population base. The
relatively lower success rate (78%)
in the interpositional vein grafts
seen in this study, may well attest
to this delay in presentation. Nearly
all of the patients in this category
would fall into Kolker’s “chronic”
subgroup. Although he remarks
that their experience did not show
any difference between the acute
and chronic patients, he does go
on to state that any person with
evidence of compromised blood
flow within the zone of injury
should receive a proximal graft.4
The patient cohorts within this
study reveal their preference for
proximal vascular anastomosis
despite their conclusions, as only 35
flaps were placed distally compared
to the 416 placed proximally. In
fact, Kolker is correct when he
states, “the decision to perform
free flap microanastomosis to
clearly uninjured vessels proximal
to the zone of injury [sic] must be
weighed against the anatomic and
technical difficulties of performing
such an anastomosis.”4 However,
in our population, the numbers of
“selected” patients are relatively
small and the amount of fibrosis and
vascular damage is significant by
the time the patient presents to the
operating room for tissue coverage.
In addition, this study reports
those receiving a free tissue transfer
for oncologic repair were successful
at a rate of 93% (14 of 15).12,13 A local
anastomosis was employed a majority
of the time accounting for 73% of
the vascular supply to the free flaps.
The local anastomosis was preferred
in this population especially in all
of the breast cases as they were all
immediate reconstructions. (Table
7) The interpositional vein graft was
employed in about half of the head
and neck cases because of either
poor quality of the native vessels
due to prior exposure to radiation,
or the distance from the vascular
supply to the defect was too great.
All of the interpositional vein grafts
survived without complication.
It was interesting to note also
that the general nutritional status
and length of stay in the hospital
4/23/20103:10:51PM
Table 6.
Timing
Interpositional Vein Grafts
Local Anastomosis
Overall
754 days
461.5 days
637 days
142.4 days
78 days
116.4 days
17 days
18.8 days
19.1 days
Interpositional Vein
Grafts
Local
Anastomosis
0
5 (45%)
4 (100%)
5 (45%)
0
1 (10%)
Initial Insult to Consult (mean)
Without Oncologic Cases (mean)
Consult to OR (mean)
Table 7.
Breast Cancer
Head and Neck Cancer
Osteogenic Sarcoma
was consistent in both populations.
This is somewhat counterintuitive as
common experience in the literature
has stated that the complication rate
for interpositioned vein grafts is
more significant. It should also be
noted, in addition, that the patient’s
nutritional status did not seem to be
a factor in the success or failure of
the flaps they received. Certainly, it
is well known that nutrition plays
a vital role in wound healing and
this study does not argue to the
contrary especially in the survival
of free tissue transfers, but that it
was interesting that it did not seem
to play a more prominent role.
The zone of injury remains the
mysterious gate-keeper surrounding
any traumatic wound, either from
blunt or penetrating injury, chronic
inflammation of infection, or the
degeneration of tissues after radiation
therapy. Experience with free tissue
transfers with anastomoses at the
local level has advanced to the point
of creating reliable and reproducible
wound coverage. The experience
at this tertiary care center has led
to the conclusion that the use of
a vein interposition graft should
still be employed especially in
cases where wounds do not have
defined zone of injury, or when the
field has been irradiated, or finally,
when the defect to be covered is
too distant from a reliable vascular
supply. The interpositional vein
graft allows a consistent, reliable,
vascular pedicle with the flexibility
to access wounds throughout the
body and should be maintained in
the armamentarium of flap surgery.
References
1. Bayramicli M, Tetik C, Sonmez S, et al.
Reliability of primary vein grafts in lower
extremity free tissue transfers. Ann Plast
Surg. 2002;48(1):21-9.
2. Spiro SA, Oppenheim W, Boss WK,
Schneider AI, et al. Reconstruction of the
Lower Extremity after Grade III Distal Tibial
Injuries Using Combined Microsurgical
Free Tissue Transfer and Bone Transport
by Distraction Osteosynthesis. Ann Plast
Surg. 1993;30(2):97-104.
3. Benacquista T, Kasabian A, Karp N. The
Fate of Lower Extremities with Failed Free
Flaps. Plast Reconstr Surg.
1996;98(5):834-40.
4. Kolker AR, Kasabian, AK, Karp NS, et al.
Fate of free flap microanastomosis distal to
the zone of injury in lower extremity
trauma. Plast Reconstr Surg.
1997;99(4):1068-73.
5. Hallock GG. Liability of recipient vessels
distal to the zone of injury when used for
extremity free flaps. J Reconstr Microsurg.
1996;12(2):89-92.
6. Godina M. Early microsurgical
reconstruction of complex trauma of the
extremities. Plast Reconstr Surg.
1986;78(3):285-92.
7. Freedman AM, Meland NB. Arteriovenous
shunts in free vascularized tissue transfer
for extremity reconstruction. Ann Plast
Surg. 1989;23(2):123-8.
8. Wells MD, Bowen CV, Manktelow RT, et al.
Lower extremity free flaps: a review. Can J
Surg. 1996;39(3):233-9.
9. Heller L, Levin LS. Lower Extremity
Microsurgical Reconstruction. Plast
Reconstr Surg. 2001;108:1029
10. Stompro BE, Stevenson TR.
Reconstruction of the traumatized leg: Use
of distally based free flaps. Plast Reconstr
Surg. 1994;93(5):1021-5.
11. Isenberg JS, Sherman R. Zone of injury: a
valid concept in microvascular
reconstruction of the traumatized lower
limb? Ann Plast Surg. 1996;36(3):270-2.
12. Disa JJ, Hu QY, Hidalgo DA. Retrospective
review of 400 consecutive free flap
reconstructions for oncologic surgical
defects. Ann Surg Onc. 1997;4(8):663-9.
13. Wei F, Demirkan F, Chen HC, et al. The
outcome of Failed Free Flaps in Head and
Neck and Extremity Reconstruction: What
Is Next in the Reconstructive Ladder?
Plast Reconstr Surg. 2001;108(5):1154-60.
14. Vlastou C, Earle AS. Short saphenous vein
grafts as an aid to microsurgical
reconstruction of the lower extremity. J
Reconstr Microsurg. 1988;4(2):145-54.
15. Lin CH, Mardini S, Lin YT, et al. Sixty-five
clinical cases of free tissue transfer using
long arteriovenous fistulas or vein grafts. J
Trauma. 2004;56(5):1107-17.
16. Park S, Han HS, Lee TJ. Algorythm for
Recipient Vessel Selection in Free Tissue
Transfer to the Lower Extremity. Plast
Reconstr Surg. 1999;103(7):1937-48.
May/June 2010 | Vol. 106 23
4/23/20103:10:52PM
Successful Pregnancy Following Conservative Surgical
Shon P. Rowan, MD
Michael L. Stitely, MD
Roger C.Toffle, MD
WVU School of Medicine
Department of Obstetrics and
Gynecology
Abstract
Background: An invasive mole is a
form of persistent trophoblastic disease.
The traditional surgical treatment is
hysterectomy.
Case: A young nullipara presented
with a positive pregnancy test 6 months
following a suction curettage for an
incomplete abortion. Radiologic imaging
was suspicious for intramural ectopic
gestation. She was treated with
methotrexate but became
thrombocytopenic with failure to resolve
the abnormal gestation. Surgical excision
of the mass was performed. Pathologic
evaluation revealed the diagnosis of
invasive molar pregnancy. The β-hCG
levels remained negative for greater than
a year. The patient subsequently
conceived and underwent a cesarean
delivery of a viable infant at 36 weeks
gestation.
Conclusion: Conservative surgical
excision can successfully treat invasive
molar gestation. This should be
considered for patients who desire future
fertility and have contraindications to
medical therapy.
Introduction
Gestational trophoblastic disease
is an abnormal pregnancy occurring
from an aberrant fertilization event.
This maternal tumor is unique
because it arises from fetal tissue.1 An
invasive molar gestation is a variation
of a hydatiform mole where the
hydropic villi invade the uterine wall
or blood vessels and develops only
after uterine evacuation of a molar
pregnancy.2,3 Excessive trophoblastic
overgrowth and penetration of
trophoblastic elements into the
myometrium are distinguishing
features of an invasive molar
gestation which tends to be locally
invasive and usually does not result
in widespread metastatic disease.4
Persistent gestational trophoblastic
disease is normally treated with
single agent chemotherapy with
methotrexate. Medical treatment
failures are usually treated by
hysterectomy. Treatment of
invasive molar gestation by
conservative surgical excision has
been described in the literature.
However, 7 of 22 patients in one trial
required additional chemotherapy
following the surgical excision for
persistent β-hCG elevations.5
Case
A 24-year-old woman presented
to our facility with the presumed
diagnosis of an intramural ectopic
pregnancy. Six months prior
to admission, she underwent a
suction curettage for a presumed
incomplete abortion with pathology
showing some hydropic changes
of the villi. She was placed on oral
contraceptives and had regular
monthly menses until 2 months
prior to admission. A pregnancy test
was obtained and was positive but
serial levels of beta-hCG plateaued.
The patient was hemodynamically
stable with no discomfort. Her
quantitative β-hCG on admission was
6283 IU. Transvaginal ultrasound (See
Figure 1) revealed a cystic structure
within the uterine wall with a marked
increase in vascularity, suspicious
for intramural ectopic pregnancy.
Because of the lack of symptoms,
a normal CBC, renal, and liver
function tests and the fact that her
HCG levels were already plateauing,
it was decided to attempt to treat
her with single dose methotrexate.
She was given one dose of 50 mg/
m2 of intramuscular Methotrexate,
and her beta-hCG levels decreased
to 5777 IU on the second day
after methotrexate injection.
Follow-up quantitative β-hCG
values initially fell to 5081 IU but
then plateaued at 5011 IU. Repeat
ultrasound showed increased
size and vascularity of the cystic
mass along with a small amount
of cul-de-sac fluid. At this point,
Figure 1.
Ultrasound image showing gestational sac located in the posterior uterine wall. Note
the location separate from the endometrial stripe.
4/23/20103:10:53PM
Figure 2.
Laparoscopic image showing the focal distension of the posterior myometrium.
tissue. The capsule and its contents
were removed using the monopolar
electrosurgical device. Flowseal and
Gelfoam were placed in the base
of the myometrial incision, and the
defect was then closed using 2-0
chromic. The serosa was closed using
3-0 vicryl in a baseball suture fashion,
and the Penrose drain was removed.
The total estimated blood loss for
the procedure was 300 mL. The
pathologic evaluation of the tissue
revealed an invasive molar gestation.
Her quantitative β-hCG levels
remained negative for over 1 year.
She then became pregnant and
underwent a Cesarean delivery at
36 weeks gestation due to concern
for uterine rupture if labor were to
occur. Small bowel was noted to
be adherent to the uterine fundus.
The uterine wall was intact.
Conclusion
the diagnosis of invasive molar
gestation as opposed to intramural
ectopic pregnancy was suspected.
She underwent a chest x-ray,
which was normal. Her follow-up
platelet count had fallen to 71,000
but there was no other evidence
of bone marrow suppression. She
underwent leucovorin rescue as
the thrombocytopenia was felt to
be due to the methotrexate. Her
platelet count improved to 121,000
after one dose of leucovorin. Further
methotrexate therapy, even in the
context of a multi-dose regimen,
was felt to be contraindicated.
Interventional radiology was
consulted and performed a
uterine artery embolization in
an attempt to decrease blood
flow to the area in case surgical
intervention was necessary.
Her quantitative β-hCG initially
dropped following the uterine artery
embolization but then began to rise
once again to a level of 3342 IU.
Laparoscopic findings included a
markedly edematous left tube, left
broad ligament, and left proximal
round ligament, marked dilation of
the vessels in the left broad ligament
and infundibulopelvic ligament
and a 2 cm x 2 cm x 3 cm mass
protruding from the left posterior
wall of the uterus (See Figure 2).
Laparotomy was performed and the
round ligaments were ligated and
divided in order to reduce the time
needed for hysterectomy in case of
excessive bleeding. A bladder flap
was developed, the anterior sheath of
the broad ligaments opened, and the
ligaments were penetrated lateral to
the ascending branches of the uterine
artery. A Penrose drain was passed
through these defects to provide a
tourniquet effect to the ascending
branches of the uterine arteries. A
rubber-shod clamp was placed over
the proximal left tube and dilated
vessels in an attempt to interrupt
collateral blood flow. The serosa
overlying the mass was injected with
dilute vasopressin and the serosa
was opened using a monopolar
electrosurgical device. The mass
had a capsule that was immediately
beneath the serosa and extended
into the myometrium and contained
villous-like material and dense
The initial treatment for persistent
trophoblastic disease in the form
of invasive molar gestation is
single agent chemotherapy with
methotrexate.7 If chemotherapy
fails or is contraindicated
and future fertility is desired,
conservative surgical excision may
be appropriate for treatment and
definitive diagnosis. In our case,
this approach led to negative βhCG levels for greater than 1-year
post therapy and the subsequent
delivery of a viable infant.
References
1. Berkowitz RS. Goldstein DP. Chorionic
tumors. N Engl J Med. 1996;23:1740-8.
2. Stenchever MA, Droegemueller W, Herbst
AL, Mishell D. Gestational Trophoblastic
Disease. In Comprehensive Gynecology.
St Louis: Mosby; 2001. p. 1047-51.
3. Kennedy AW. Persistent nonmetastatic
gestational trophoblastic disease.
Semin Oncol. 1995;22:161-5.
4. Cunningham FG, Gant NF, Leveno KJ,
Gilstrap III LC, Hauth JC, Wenstrom KD:
Diseases and Abnormalities of the
Placenta. In Williams Obstetrics 21st
Edition. Seils A, Noujaim SR, Davis K. New
York: McGraw-Hill; 2001. p. 827-52.
5. Kanazawa K, Sasagawa M, Suzuki T,
Takeuchi S. Clinical evaluation of focal
excision of myometrial lesion for treatment
of invasive hydatidiform mole. Acta Obstet
Gynecol Scand. 1988;67:487-92.
May/June 2010 | Vol. 106 25
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Geographic and Temporal Comparisons of ATV Deaths
Loretta Cain, MPH
Department of Community Medicine,
West Virginia University
Jim Helmkamp, PhD
National Institute for Occupational Safety
and Health, Centers for Disease
Control and Prevention
Abstract
During the 9-year period from 20002008, West Virginia experienced 301
deaths related to All-terrain Vehicles
(ATVs). The distribution of ATV deaths
across the top 20 counties in West
Virginia accounted for nearly seventy
percent of the ATV-related deaths during
the 9-year study period. Time-of-day was
a significant predictor of population-based
rates, and a 34% decrease in the fatality
rate from 2.94 in 2006 to 1.93 in 2008
occurred. We opine that the decline in
ATV mortality is possibly due to better
enforcement of the (WV Code Chapter
17F), mandatory ATV regulations passed
by the West Virginia State Legislature in
2004. Improved safety vigilance and ATV
operator adherence to manufacturers’
safety guidelines may have also
contributed to the decreasing incidence of
ATV deaths. While the current downward
trend is most welcome, more attention
should be directed towards high-risk
behaviors including alcohol and drug
abuse and driving on paved surfaces.
Introduction
Previous research has described
the epidemiology and characteristics
of ATV-related mortality in West
Virginia.1-6 During the decade of the
1990s, West Virginia had the second
highest number of ATV deaths (124)
compared to all other states, and a
fatality rate of 0.7 deaths per 100,000
population; a rate significantly higher
than any other state.2 Adolescents
and the elderly were identified
as high-risk subgroups.4,5 Based
on death certificate information,
West Virginia has experienced
at least 301 ATV-related deaths
from 2000 through 2008.
About one-fourth of these deaths
have occurred in children less than 18
years of age; 95% of the victims were
not wearing helmets and 15% were
passengers. About one-third of ATV
crashes have occurred on surfaces not
intended for safe ATV use including
public roads, streets and highways.
States, such as West Virginia with no
ATV safety requirements (prior to
2004), experienced an ATV-related
fatality rate double that of states with
some level of ATV safety regulation.2
A March 2008 Morbidity and
Mortality Weekly Report article
reported that lower socioeconomic
status, lower level of education
attained, and single or divorced
marital status were associated with
higher rates of ATV-related deaths
in West Virginia from 1999-2006.7 To
date, little has been done to describe
geographic and temporal patterns
of ATV deaths across West Virginia,
particularly in those counties which
account for most of the state’s ATV
Table 1. Distribution and rate of ATV-related deaths by County, 2000-2008.
Deaths
Proportion
of Deaths
2004
Population
Fatality Rate
per 100,000
Kanawha*
20
6.64%
195,218
1.14
McDowell*
17
5.65%
24,726
7.64
Mingo*
15
4.98%
27,389
6.09
Monongalia
14
4.65%
83,918
1.85
Fayette*
12
3.99%
47,049
2.83
Lincoln*
12
3.99%
22,564
5.91
Raleigh*
12
3.99%
79,175
1.68
Cabell*
11
3.65%
94,801
1.29
Jackson
11
3.65%
28,477
4.29
Wyoming*
11
3.65%
24,698
4.95
Logan*
9
2.99%
36,502
2.74
Roane
8
2.66%
15,359
5.79
Boone*
8
2.66%
25,721
3.46
Hampshire
7
2.33%
21,542
3.61
Marion
7
2.33%
56,453
1.38
Mason*
7
2.33%
25,941
3.00
Putnam
7
2.33%
53,836
1.44
Braxton
6
1.99%
14,950
4.46
Calhoun
6
1.99%
7,415
8.99
Mercer*
6
1.99%
62,070
1.07
Other 35 Counties
95
31.56%
860,540
1.23
State
301
100.00%
1,808,344
1.85
County
* located in southern third of state
4/23/20103:10:54PM
Table 2. Population-based ATV
fatality rates, 2000-2008
Year
Deaths
Fatality Rate
(per 100,000)
2000
15
0.77
2001
20
1.14
2002
27
1.52
2003
35
2.07
2004
32
1.83
2005
39
2.11
2006
52
2.94
2007
45
2.56
2008
36
1.93
Total
301
1.85
deaths. Therefore, the purpose of
this report was to identify the top 20
counties in West Virginia for ATV
mortality, and determine if temporal
features such as month, day-of-
weekday (Monday-Thursday)
or weekend (Friday-Sunday).
R statistical software was used
to fit the count data into a Poisson
regression model using populationbased ATV mortality rates as the
response variable and the seasons,
times of day and weekend versus
weekday as predictor variables.
Separate models were fitted for
seasons, time-of-day and weekend
versus weekday. Rates were
calculated using U.S. Census
Bureau data;8 the WV and county
populations for 2004. The midpoint
in the 9-year study period was
used as denominator values.
week, or time-of-day may influence
mortality patterns from 2000-2008.
Methods
Death certificates, obtained from
the West Virginia State Registrar,
for the 301 ATV-related deaths that
occurred in West Virginia from 20002008 were reviewed. Information
related to the county where the
fatal crash occurred, year, month,
day-of-week and time-of-day were
recorded and entered into an Excel
spreadsheet. Time-of-day was
grouped as early morning (Midnight
- 5:59 am), morning (6:00 am-11:59
am), afternoon (Noon - 5:59 pm) and
evening/night (6:00 pm-11:59 pm).
Months were grouped in seasons:
Spring (March, April, May), Summer
(June, July, August), Fall (September,
October, November), and Winter
(December, January, February).
Days-of-week were grouped as
Helping West Virginia pHysicians
Results
The distribution of ATV deaths
across the top 20 counties in West
Virginia is shown in Table 1.
These counties, out of the state’s
55 counties, accounted for nearly
take the right path…
…in litigation, privacy and security compliance, certificate of need, medical staff and professional
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Charleston
health care practice group
Ryan A. Brown
Robert L. Coffield
Alaina N. Crislip
J. Dustin Dillard
Sam Fox
Michele Grinberg
John D. Hoffman
Amy R. Humphreys
Morgantown
Justin D. Jack
Richard D. Jones
Edward C. Martin
Mark A. Robinson
Amy L. Rothman
Don R. Sensabaugh, Jr.
Salem C. Smith
Stephen R. Brooks
Stacie D. Honaker
Wheeling
David S. Givens
Phillip T. Glyptis
Robert C. James
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May/June 2010 | Vol. 106 27
4/23/20103:10:55PM
Table 3. Time of ATV crash as a predictor of fatality rates
Time Period
Estimate ± Std Error
Significance
Midnight – 5:59 am
-0.02 ± 0.40
NS
6:00 am – 11:59 am
0.12 ± 0.10
NS
Noon – 5:59 pm
0.16 ± 0.07
0.02
6:00 pm – 11:59 pm
-0.12 ± 0.07
NS
seventy percent (205 of 301) of the
ATV-related deaths during the 9‑year
study period. Further, twelve of the
20 counties, which are located in the
southern part of the state, accounted
for over 46% of all the deaths (140
of 301). These twelve counties also
accounted for about 38% of the state’s
population and 26% of the land area.8
Calhoun County, whose population
ranks 50th in the state, experienced
the highest population-based rate of
8.99 per 100,000 population. At the
other end of the spectrum, Kanawha
County ranked 1st in population with
a fatality rate of 1.14, second lowest
among the 20 top counties. The rate
for the remaining 35 counties was
1.23 and for the entire state, 1.85.
During the first six years of the
study period, deaths increased
consistently from 15 in 2000
to a record high of 52 in 2006
(see Table 2). Fatality rates also
increased proportionally.
Sixty-four percent of the deaths
occurred on the weekend with
Saturday alone accounting for a
quarter of the deaths. Deaths during
the Summer season accounted
for about 36% of the ATV deaths.
Nearly 70% (208 of 300) of the
ATV deaths occurred between
noon and midnight. Season and
weekend versus weekday were
not predictors of population-based
rates. Time-of- day however, was a
significant predictor of populationbased rates (see Table 3). There was
a residual deviance: 15.389 on 15
degrees of freedom, suggesting that
the data fit the model extremely
well. During the afternoon period
(i.e., noon to 5:59 pm) there was a
significant proportional increase in
the number of ATV deaths (p =.02).
Discussion
After the initial geographical
analyses, one might conclude that
because Kanawha County had the
greatest population and the highest
number of ATV-related deaths, it
should follow that Kanawha would
have the highest fatality rate, as
well. Results presented above show
that this is definitely not the case.
In fact, Calhoun County, with a
2004 population less than 4% of
Kanawha’s and 14 fewer ATV deaths,
had a fatality rate nearly eight times
higher, 8.99 and 1.14, respectively.
This finding supports the observation
by Rodgers in his study of national
ATV fatality rates from 1990-1999,
where he reported that the rural
nature of a state contributed to
rate differences.9 While relatively
higher rates have been observed in
many of West Virginia’s counties,
the overall rate for the state from
2000-2008 is consistent with rates
reported in earlier studies.1,2,9
Even though ATV fatalities in
West Virginia continue to be a local
as well as a national public health
concern, Table 2 shows a decline in
ATV population-based fatality rates
after 2006. The 34% decrease in the
fatality rate from 2.94 in 2006 to 1.93
in 2008 is significant and should
give us pause. We opine that the
decline in ATV mortality is possibly
due to better enforcement of the
(WV Code Chapter 17F), mandatory
ATV regulations passed by the
West Virginia State Legislature in
2004.10 Improved safety vigilance
and ATV operator adherence to
manufacturers’ safety guidelines
may have also contributed to the
decreasing incidence of ATV deaths.
While the current downward trend
is most welcome, more attention
should be directed towards two
continuing high-risk behaviors.
Review of medical examiner records
and toxicology data of 112 fatal ATV
crashes from 2004-200611 revealed
that alcohol was detected in the blood
of 50% of the decedents and of those,
88% had blood alcohol concentrations
at or over the legal limit of 0.08%.
Drugs of abuse, including marijuana,
opioid analgesics, and diazepam
were identified in 21% of the deaths.
The location of the crashes is also
of major concern. Recent data, from
a report prepared for Governor
Manchin,12 showed that at least
53% of the fatal crashes occurred
on paved surfaces including streets
and highways – many of which are
in the counties described in this
study. While some of these locations
were legal for riding in accordance
with the 2004 law,10 many were not.
Manufacturers have continuously
recommended that ATVs not be
operated on paved surfaces such as
asphalt and concrete. ATV tires are
bulbous, with low air pressure and
wide treads that do not grip well
on hard surfaces like roads. Stricter
enforcement of this part of the law
is strongly warranted.10 In addition,
the required ATV Awareness Course
should be strengthened by more
aggressively addressing these highrisk behaviors. If ATV operators
are made more aware of these
risks, then ATV mortality should
continue its recent downward trend.
4/23/20103:10:55PM
Acknowledgement
This research was supported
by grant # 5R49CE001170 from
the National Center for Injury
Prevention and Control, CDC,
to the West Virginia University
Injury Control Research Center.
Contents are sole the responsibility
of the authors and do not represent
official views of the CDC.
References
1. Helmkamp JC. ATV-related deaths in West
Virginia: 1999-2003. WV Med J
2003;99:224-7.
2. Helmkamp JC. A comparison of statespecific all-terrain vehicle-related death
rates, 1990-1999. Am J Pub Health
2001;91(11):1792-5.
3. Helmkamp JC. Estimated annual cost of
all-terrain vehicle-related deaths in West
Virginia: 1990-1999. WV Med J
2002;98:24-25.
4. Helmkamp JC. Adolescent all-terrain
vehicle deaths in West Virginia, 19901998. WV Med J 2000;96:361-3.
5. Helmkamp JC. All-terrain vehicle-related
deaths among the West Virginia elderly,
1985 to 1998. Am J Pub Health
1999;89(8):1263-4.
Prevention. All-terrain vehicle related
deaths-West Virginia, 1985-1997. MMWR
1999;48(1):1-4.
Prevention. All-terrain vehicle related
deaths-West Virginia, 1999-2006. MMWR
2008;57(12):312-315.
8. US Census Bureau. GCT-PH1-R,
Population, Housing Units, Area and
Density for West Virginia, by County, 2000.
9. Rodgers GB. Factors associated with the
all-terrain vehicle mortality rate in the
United States: An analysis of state-level
data. Accid Anal Prev 2008;40(2):725-732.
10. West Virginia Code. Chapter 17F, allterrain vehicles. March 2004. Available
online at: www.legis.state.wv.us/wvcode/
code.cfm?chap=17&art=1
11. Hall AJ, Bixter D, Helmkamp JC, et al.
Fatal all-terrain vehicle crashes – injury
types and alcohol use. Am J Prev Med
2009 (in press).
12. Helmkamp JC, Ramsey WD, Haas SM,
Holmes M. All-terrain vehicle (ATV) Deaths
and injuries in West Virginia: A summary of
surveillance and data sources. Charleston,
WV: Criminal Justice Statistical Analysis
center, Division of Criminal Justice
Services, Department of Military Affairs
and Public Safety, February 2008.
Available online at: www.wvdcjs.com/
statanalysis.
Charleston WV
800-788-3844
Parkersburg, WV
304-485-6584
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May/June 2010 | Vol. 106 29
4/23/20103:10:55PM
Special Article |
From Medical Student to Board Certified Physician
Philip Eskew, JD, MBA
2nd Year Medical Student
West Virginia School of Osteopathic
Medicine
Abstract:
An examination of two types of
educational tracks used by medical
students seeking a faster route to practice:
1) “3+3” programs that combined the final
year of medical school with the first year
of a primary care residency, and 2)
graduating from medical school after only
three years. The “3+3” programs were
discontinued despite reports indicating
their success. Three year medical school
options are still available at a handful of
medical schools. Finally, the paper will
explore why and how medical schools
might wish to enact a three year curricular
option.
Introduction
Are we forcing new physicians
to endure too much clinical training
before receiving a full license to
practice medicine? In the 1970s, it
was not uncommon for physicians
to open up a practice after only
three years of clinical time. Today’s
medical students average over five
years of clinical education. If a 22
year old entering medical student
decides to pursue a primary care
field, the earliest age this student can
expect to be fully licensed to practice
medicine is 29. If the student decides
to pursue a more specialized field,
such as a seven year neurosurgery
residency followed by a two year
fellowship in endovascular surgical
neuroradiology, then he can expect
to obtain full practice rights at 35!
Students beginning to practice
sooner will have less debt, and more
years of life to earn revenue as a
practicing physician. The long time
period between entrance into medical
school and full practice capability
can make high amounts of student
loan debt much more intimidating. In
2005, Osteopathic graduates reported
average educational loan debt of
$149,800 per person.1 In a more recent
American Association of Medical
Colleges (AAMC) study, the average
amount of student debt for the class
of 2008 was $154,607.2 Some argue
that medical school tuition should be
lowered, but one might be surprised
to learn that decreases in tuition
would do relatively little to affect
medical student debt.3 Shortening the
time needed to obtain full practice
rights has been shown to have the
greatest impact.3 How can we amend
medical education to allow students
to obtain full practice rights earlier?
There are only two ways to
shorten the time it takes currently
matriculating medical students
to obtain a license to practice: 1)
decrease the time spent in residency,
and/or 2) decrease the time spent
in medical school. Other options,
such as combining undergraduate
college education with medical
school, are inherently limited in scale,
and will not be discussed. We can
either develop accelerated residency
tracks that permit students to enter
the profession more rapidly, or
develop curricular tracks that allow
students to graduate medical school
after three years. Unfortunately,
the accelerated residency choice is
no longer an option for American
Osteopathic Association (AOA) or
Accreditation Council for Graduate
Medical Education (ACGME)
approved programs, especially
for ACGME residencies, where
pilot programs were attempted
with great success only to be
discontinued anyway. Three year
medical curricular options show
promise, and the adoption of a three
year curricular option is a realistic
possibility for both osteopathic
and allopathic medical schools.
I. Graduate Medical
Education Considerations
Many primary care residencies
developed highly regarded “3+3”
programs where the final year
of medical school was combined
with the first year of the student’s
residency. If many students,
professors, schools, and hospitals
favored these programs, why did the
ACGME approved “3+3” programs
disappear? It was not a funding issue.
In the combined year, the rookie
physicians paid fourth-year tuition to
their medical school, and the hospital
received first year Medicare resident
funding for the same student.4 It was
not a quality issue. Hospitals eagerly
embraced accelerated students, and
multiple studies have demonstrated
the high quality of the accelerated
graduates.4,5 The ACGME has not
explicitly stated why the programs
were discontinued, leaving one
to speculate about many possible
reasons. Did the ACGME feel that
it was stepping on the toes of the
Liaison Committee on Medical
Education (LCME) by working
with medical students that had not
yet received their degree? Was it a
political problem - did residency
directors from excluded programs
complain that they were unable
to compete for the best residents
interested in primary care?
“3+3” Programs Were
Successful
Accelerated family medicine
residency programs at Marshall
University and the University of
Tennessee attracted motivated
students, often those in the top of
their class.4,5 These schools were
two of twelve to receive approval
in 1989.5 In addition to the saved
time, students were attracted to
4/23/20103:10:56PM
| Special Article
the prestige associated with an
accelerated program.4,5 Hospitals
were pleased with the quality of the
students. Authors of the Marshall
study stated “[i]t has been a
consistent impression of the faculty
that most first-year accelerated
residents have generally become
indistinguishable in performance
from the traditional PGY-I residents
at six to nine months following
orientation.”5 The program
successfully encouraged its trainees
to practice in West Virginia—81% of
residents remained in West Virginia.5
The Tennessee case demonstrates
the financial contentment of all parties
involved. Students benefited—they
received residency pay a year earlier,
and were able to practice one year
sooner. The medical school was
content—it still received fourth
year tuition dollars from the now
“resident” students. Hospitals were
content—they were pleased with
the quality of the students, and they
continued to receive Medicare GME
funding for the residency positions.
The Tennessee authors also noted that
“[b]eneficial outcomes of accelerated
residencies include a savings to
society and taxpayers since there is a
decrease in the time and educational
financing for the production of
a well-trained physician.”4
The following observations
from the University of
Tennessee were promising.
“The key finding of this study
is that, when compared to the
traditional curriculum of 4 years
of medical school and 3 years
of residency (4+3), residents in
the accelerated curriculum (3+3)
demonstrated performance scores
equal to or better than their nonaccelerated counterparts. Using
annual In-training Examination
scores beneath the 20th percentile as
one indicator, accelerated residents
scored better than their peers.
Further, these accelerated residents
frequently distinguished themselves
as chief residents and with other
honors. These Tennessee students
were, on average, in the middle
of their classes academically, and
[the] data suggest[s] that students
need not be at the very top of their
class academically to succeed in an
accelerated program. All students
achieved the objective milestones of
licensure and passage of the ABFM
certification examination, despite the
shorter and less-costly training.”4
Will Residency Programs
Generate Independent
Accelerated Options?
If residencies decide to
increase their focus on established
competencies rather than lockstep
“meaningful contact hours,”
residency programs could offer
residents the opportunity to complete
the residency at an accelerated pace.
These new accelerated tracks would
need to overcome two main hurdles.
First, the AOA and ACGME would
need to rewrite program certification
language establishing an exact
number of required residency years
before a student may become board
certified. When a student has met
these competencies and passed the
licensing examination, the student
could be fully certified without
regard to how quickly these tasks
may have been accomplished.
The second barrier is imposed
by hospitals, which have numerous
financial incentives to prevent rookie
physicians from finishing residency
earlier. Convincing hospitals to allow
residents to leave “early” will be
difficult because residents provide a
cheap source of labor, and hospitals
average almost $100,000 of Medicare
funding per resident.6 Hospitals
do not want to give up this direct
source of income, especially during
the resident’s last year, when the
resident is providing very efficient
and effective care. Outdated payment
incentives established by the Centers
for Medicare and Medicaid Services
(CMS) increase hospital efforts
to defend an old and inefficient
training system. Actions by Congress
to correct misguided financial
incentives may be required before
accelerated residencies are possible.
A Creative Family
Medicine Program
Today, family medicine and other
primary care residencies struggle
to retain talented students, and it is
not uncommon for allopathic family
medicine residencies to be filled
entirely by international medical
graduates. The West Virginia Family
Medicine Rural Scholars Program
(WVFMRSP) attempts to entice
students into family medicine with
a similar prestige factor, but without
the ACGME prohibited reduced year
of training. The student’s fourth year
of medical school is treated like the
first of residency, but the student
still must complete three years of
residency after graduating from
medical school. Program participants
receive a $10,000 stipend during
their fourth year of medical school,
avoid the match process, and will
have considerable unscheduled
time to conduct research during
their final residency year.7
The WVFMRSP is a creative idea
given West Virginia University’s
inability to enact a “3+3” program.
In the meantime, other schools
might increase their competitiveness
for residents by adopting similar
programs. The WVFMRSP treats a
fourth year medical student just like a
first year resident with relatively few
benefits to the student. The student
does receive the $10,000 stipend,
but does not receive residency pay,
and the student will still spend
three more years as a resident.
While the research year might be
very valuable and important to
some students, one might speculate
that the final year is dedicated to
research because the young physician
has completed family medicine
training, but the residency director is
simply not permitted to “graduate”
students due to the requirements
of the ACGME and/or AOA. The
WVFMRSP’s existence provides
evidence that students are capable
of beginning residencies after their
third year of medical school, and
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Special Article |
that preventing students from
obtaining residency credit during
their fourth year cheats the students
out of a year of full-time practice.
Combined Medical School
and Residency Years (“3+3”
Programs) Are Not Permitted
Despite “3+3” program success,
these programs stopped enrolling
new students in 2001. Fourth year
medical students are currently barred
from participating in any residency
program accredited by the AOA or
the ACGME.8,9 The “Accreditation
Document for OPTI [Osteopathic
Postdoctoral Training Institution] and
the Basic Document for Postdoctoral
Training Programs” published by the
AOA states in section L subsection 2.1
that “the program shall enroll only
graduates of COCA [Commission on
Osteopathic College Accreditation]
accredited COMs [Colleges
of Medicine].”8 The ACGME
Institutional Requirements in section
II. A. 1. similarly states that residency
applicants must be “graduates” of a
medical school.9 Without a change
to the “graduate” requirement in
these documents, “3+3” programs
will never again be permitted.
If one were to convince the
ACGME or AOA to allow nongraduates (i.e. fourth-year medical
students) to enter residency
programs, many state laws
use similar language requiring
“graduate” status to achieve the
temporary practice rights afforded
to medical residents. The West
Virginia Secretary of State Code of
State Rules contains a regulation
that “[a]n application for an
educational training permit shall
include proof that the applicant
is a graduate of a medical school
approved by the AOA.”10 In many
states, regulations may need to be
amended to provide exceptions
for “3+3” program participants.
Drs. Steven Berk, Michael Ragain,
and Troy Fiesinger attempted to start
a “3+3” family medicine residency
program at Texas Tech by submitting
a proposal to the ACGME in early
2009.11 They hoped to establish
a “3+3” example that could be
followed by multiple family practice
residencies across the nation.11
According to Drs. Berk and Ragain,
favorable responses to the proposed
accelerated “3+3” program were
received from the American Board of
Family Medicine, the Association of
Departments of Family Medicine, and
the Association of Family Medicine
Residency Directors.11 In spite of this
support, the proposal was declined
by the ACGME. The group redirected
its efforts toward designing a
three year medical degree, and
in March of 2010 it announced
LCME approval for a three year
medical school option open to a
limited number of medical students
committed to family practice.12
II. Analysis of the Three Year
Medical School Curricular Option
Reducing the length of medical
school to three years leads to
considerable financial savings for
future physicians and the reduced
amount of time in school may make
the medical field more attractive
to potential applicants. A March
2006 University of Pennsylvania
study determined that “even if total
medical school tuition remained
constant, a one year reduction in
the duration of medical school still
yields a financial benefit of $100,000
or more to future physicians.”3
Papers by Dr. Whitcomb and
Dr. Irby developed at the Josiah
Macy Foundation’s Conference
on “Revisiting the Medical School
Educational Mission at a Time of
Expansion” make salient arguments.
Dr. Whitcomb’s article
“Shortcomings in the Pursuit
of Medical School Education
Mission” states as follows:
“At present, no medical school
requires all students to experience
the same specific coursework during
the four years of the education
program. Indeed, until relatively
recently, the entire fourth year of
the program was elective in many
schools, and it continues to be largely
elective in most even today…. Given
the costs involved, it makes no
sense to require students to spend
a fourth year taking a variety of
electives that are not deemed to be
core elements of the program.”13
Dr. Irby’s article titled
“New Models of Medical
Education” states as follows:
“There should be three primary
options for the fourth year: 1)
direct entry into residency if all
competencies are met; 2) remediation
of deficiencies if competencies are not
met; and/or 3) pursuit of scholarship
and electives. This structure will
allow a reduction in the time to
practice, reduce student debt, and
still allow some students to pursue
elective options and scholarship.
If the student enters directly into
residency or pursues the option of
scholarship, the academic credit for
the fourth year should be double
counted for graduation from medical
school and residency training in
order to reduce the total amount of
time before entry into practice.”14
Some medical schools have
already embraced these words of
advice. As discussed above, readers
should realize that Dr. Irby’s
recommendation that the old “3+3”
programs that combined the last
year of medical school with the first
year of residency are no longer an
option. As indicated by the recent
Texas Tech experiment, interest in
“3+3” programs may be fading, while
interest in the three year medical
school curricula may be increasing.
Accelerated Medical School
Curricula Examples
We might begin by looking
at the guidance provided by the
medical school accrediting bodies.
The undergraduate requirements
specified by the COCA and LCME
offer some general guidance on
specific course subject areas.15,16
COCA specifies several subject
areas that should receive attention,
including internal medicine, family
medicine, pediatrics, geriatrics,
4/23/20103:10:56PM
| Special Article
obstetrics & gynecology, preventive
medicine & public health, psychiatry,
surgery, and radiology.15 In standard
ED‑15 the LCME recommends
that rotations in family medicine,
internal medicine, obstetrics and
gynecology, pediatrics, psychiatry,
and surgery be completed, and in
standard ED-17 that rotations in
other multidisciplinary areas, such
as pathology, be made available to
students.16 The most important piece
of guidance is found in standard
6.1.1 of the COCA documentation,
closely mirrored in standard ED-4
of the LCME documentation16, and
it states that “[t]he minimum length
of the osteopathic medical curricula
must be at least four academic years
or its equivalent as demonstrated
to the COCA. Guideline: The
curriculum should provide at least
130 weeks of instruction.”15 This 130
week requirement appears to be the
only explicit timing requirement for
medical schools seeking to develop
an accelerated curriculum. Both the
COCA and the LCME have approved
three year medical school programs
that are currently in place. In the
discussion that follows, we will
consider five medical schools (four
LCME and one COCA) that offer
innovative curricular options, each
with its own flaws and advantages.
Duke University School of
Medicine – A Research / Dual
Degree Oriented Curriculum
The traditional two years of basic
science courses are completed during
year one, required rotations are
completed in year two, year three is
spent conducting research or work
toward a dual degree, and year four
is dedicated to elective rotations.17
If the Duke student opts to pursue
a dual degree not directly related
to medicine during the student’s
third year, this student will only
be receiving three years of medical
education prior to receiving an MD.
This curricular model may not be
suitable to the majority of medical
schools. Due to the large numbers
of dual degrees and an increased
research focus, Duke medical
graduates may be more likely to
have careers outside the standard
practice of medicine – either in a
research or administrative capacity
– and Duke’s innovative curriculum
prepares its students accordingly.
With regard to dual degree programs,
Duke is not unique. Many medical
schools across the country offer dual
degree programs, and graduates
often find ways to graduate from
both programs in only four years.
University of Minnesota
Medical School – A potential
3.5 Year Curriculum?
The Minnesota curriculum
allows students to complete medical
school in 3.5 years via the “Flexible
MD” program.18 According to the
admissions department, most (if
not all) students use the program to
extend their education, and those that
have been eligible to graduate early
opted to take more electives instead.
(Paul T. White, Associate Dean of
Admissions, Minnesota Medical
School, Personal Communication on
June 24, 2009.) While some medical
schools could look to this type of
curriculum as one more possibility to
attract students with diverse needs,
it is not the ideal model for schools
looking to offer an accelerated option.
University of Calgary Faculty of
Medicine & McMaster University
Faculty of Health Sciences
Calgary students complete a fairly
standard series of first and second
year basic science courses oriented
around a “clinical presentation”
curriculum.19 The third (final) year,
students can choose the amount
of time they wish to allocate a
clinical subject area, 4 to 12 weeks,
and they have 10 weeks of pure
electives.19 McMaster students
attend school 11 months out of the
year and use a problem-based block
learning approach to qualify for
their MD degree at the end of their
third academic year.20 McMaster
students complete basic science
courses in 1.5 years, and spend
1.5 years in clinical rotations.20
A study comparing the three year
Calgary curriculum to other four
year LCME approved Canadian
curriculums stated that “the threeyear curriculum developed at the
U of C produces an equivalent
graduate—and one who might
possibly be slightly better in
communications and professionalism
skills—than those who graduate
from four-year medical schools in
Canada.”21 A Canadian Medical
Association Journal article argues
that the fourth year is not necessary,
and points out that there is no
hard evidence that the fourth year
is vital, or prepares students to
be more competent physicians.22
“Without systematic evaluations,
deans of medicine will be left with
only tradition as a defen[s]e when
education ministers demand better
evidence, given the high professional
and social costs. As for medical
students, they should ask whether
a fourth year will make them better
and wiser physicians rather than
simply older and poorer ones.”22
Lake Erie College of
Osteopathic Medicine
The Lake Erie College of
Osteopathic Medicine (LECOM) is
currently the only osteopathic school
offering a three year curriculum
leading to a doctoral medical degree.
LECOM’s three year program,
known as the Primary Care Scholars
Pathway (PCSP), is open to anywhere
from six to twelve students in each
entering class.23 The chief mechanism
used by LECOM for saving
educational time is the elimination of
“audition” clinical rotation electives.24
April of their second year students
begin to complete sixteen four-week
clinical rotations.24 For COMLEX
II & PE eligibility purposes, the
traditional ‘third year’ of medical
school is considered complete after
the eighth clinical rotation, and
comprehensive review time for both
May/June 2010 | Vol. 106 33
4/23/20103:10:57PM
Special Article |
Advantages and Barriers Medical Schools Might Encounter When Enacting a Three-Year Option
Advantages:
1)Increased Premedical Student Interest and Awareness of the medical school
a. Many students may prefer the opportunity to finish their degree one year earlier
b. Desired class size increases may be easier with higher application volumes
2)Ease of implementation - No need to make changes to basic science curricula
3)Less stress on already established clinical rotation sites
a. Fewer preceptors will be needed (since there are fewer fourth year students)
b. Decrease in administrative expenses associated with fourth year students
c. Desired class size increases will not be inhibited by a lack of preceptors
Barriers:
1)Total tuition revenues may decrease - Students electing to pursue the accelerated track might pay higher tuition
rates for the extended curriculum during their third year, but these students would not be expected to pay the
standard fourth year of tuition
2)Some clinical rotation sites might resist adjustments to their rotation schedules
3)Ensuring students obtain desired residencies by appropriately handling the temporary surge in graduating
student volume as the first class of three year graduates matriculate
4)Logistical difficulty scheduling COMLEX or USMLE exams for accelerated students
parts one and two of the COMLEX
are built into the curriculum.24,25
The PCSP created by LECOM is
a small step in the right direction.
It rewards students for entering
needed primary care areas of
family practice, general internal
medicine, and general pediatrics.
Unfortunately, the independent
study element of the program is
unappealing to many students and
physicians, and the program is only
open to a limited number of students.
The PCSP relies on contractual
obligations to ensure students to
go into one of the aforementioned
primary care areas upon acceptance
into the PCSP, and they will face
financial penalties amounting
to a fourth year of tuition if they
violate the terms of the contract.
What if other medical schools
developed three year curricular
options that were open to all
students, allowing students to elect
whether to pursue the accelerated
track at the end of their second year,
when they are more informed and
better able to make this decision?
If required third year rotations
focus heavily in primary care areas,
students will lack the “audition”
electives needed to gain interest and
experience in highly competitive
specialty areas, likely leading
most accelerated students to select
primary care residencies without
any contractual obligation. Students
uninterested in primary care may
still wish to pursue the accelerated
pathway, choosing to replace their
fourth year of medical school with
a rotating internship to prepare
for the residency of their choice.
Conclusion
The amount of knowledge that
medical students must master
has grown substantially since the
1970’s. Few continue to argue that
all of the basic science courses can
be taught in one year, even though
Duke medical students somehow
manage this challenge. In the early
1970s, it was possible to practice
general medicine after a single post
graduate internship year. This was
why it was important that future
physicians receive two years of
clinical education while in medical
school. Today, even if medical
students spend only one clinical year
in medical school, they will still have
a minimum of four years of clinical
education prior to practice. Two
years of basic sciences are needed,
but two years of clinical rotations
are often unnecessary, and students
should be afforded the opportunity
to enter residency programs after
a single year of clinical training.
The table on the opposite page may
help to clarify this difference.
Medical schools that are preparing
students to be practicing physicians,
especially in primary care specialties,
could create a three year curricular
option by removing a year of clinical
“audition” rotations while leaving
the two years of basic sciences largely
untouched. Schools might expect
students participating in accelerated
medical school curricula to achieve
similar levels of success compared to
students enrolled in “3+3” programs.
A three year medical school option
can be expected to have a larger
impact than the “3+3” programs,
which were limited to a small
number of primary care residencies.
It is important that accelerated
programs be set up as “options”
4/23/20103:10:57PM
| Special Article
Clinical Years
1970’s 3 yr program
Current 4 yr program
Proposed 3 yr program
BS
1
2
2
CR
2
2
1
PG
1
3
3
Total
3
5
4
Minimum Total Years Needed to
Graduate
3
4
3
Reach Full Practice
4
7
6
BS = Basic Science years, CR = Clinical Rotation years, PG = Post-graduate years
available to students rather than a
new requirement of all students.
This will allow schools to gauge
student interest in the accelerated
program, while accommodating
students that wish to stay for a fourth
year. Accelerated medical school
options can be clinically structured to
encourage students to enter needed
primary care fields. Students opting
to remain for a fourth year could
be permitted to pursue a variety of
clinical electives, research interests,
or dual degree work. We have found
a faster route to practice, now it is
up to medical schools to embrace it.
References
1. American Association of Colleges of
Osteopathic Medicine. Student Debt Rises.
Chevy Chase, MD: 2007. Available at:
http://www.aacom.org/about/fastfacts/
Documents/FastFacts/FF-Finance-01.pdf.
Accessed September 21, 2009.
2. Association of American Medical Colleges.
Medical Student Education: Cost, Debt,
and Loan Repayment Facts. Washington,
DC: 2008. Available at: http://www.aamc.
org/programs/first/debtfactcard.pdf.
3. Dorsey ER, Nincic D, Schwartz JS. An
Evaluation of Four Proposals for Reducing
the Financial Burden of Medical Education
and Training Facing Future Physicians.
Acad Med. 2006;81:245-251.
4. Delzell JE, McCall J, Midtling JE, Rodney
WM. The University of Tennessee’s
accelerated family medicine residency
program 1992-2002: an 11-year report.
Fam Med, 2005;37(3):178-83.
5. Petrany SM, Crespo R. The Accelerated
Residency Program : The Marshall
University Family Practice 9-year
Experience. Fam Med. 2002;34(9):669-72.
6. MedPAC Report to the Congress:
Improving Incentives in the Medicare
Program: Chapter 1: Medical Education in
the United States: Supporting Long-Term
Delivery System Reforms, June 2009, 135. Available at http://medpac.gov/
chapters/Jun09_Ch01.pdf. Accessed
September 21, 2009.
7. West Virginia University, West Virginia
Family Medicine Rural Scholars Program,
(http://www.hsc.wvu.edu/eastern/som/pdfs/
RuralCurr/RuralScholarsfinal.pdf). Revised
2009. Accessed September 21, 2009.
8. American Osteopathic Association, The
Accreditation Document for OPTI and the
Basic Document for Postdoctoral Training
Programs, 2008, Available at http://www.
do-online.org/pdf/sir_postdoctrainproced.
pdf. Accessed September 21, 2009.
9. ACGME Institutional Requirements, 2007,
Available at http://www.acgme.org/
acWebsite/irc/irc_IRCpr07012007.pdf.
10. West Virginia Board of Osteopathy, Title 24
Legislative Rule, Series 1 Licensing
Procedures for Osteopathic Physicians.
Available at www.wvsos.com/csrdocs/
worddocs/24-01.doc. Accessed September
21, 2009.
11. Ortolon K. 3+3 = family physicians: tech
wants accelerated residency program. Tex
Med. 2008;104(12):43-45.
12. Jaschik S. Will Medical Schools Join 3Year Degree Trend. Inside Higher Ed.
March 2010. Available at http://www.
usatoday.com/news/education/2010-03-25medical-school-early_N.htm.
13. Whitcomb ME, Shortcomings in the Pursuit
of the Medical School Education Mission.
Josiah Macy Foundation – Revisiting the
Medical School Educational Mission at a
Time of Expansion. 2008;1:136-160.
14. Irby DM, New Models of Medical
Education. Josiah Macy Foundation –
Revisiting the Medical School Educational
Mission at a Time of Expansion.
2008;1:161-194.
15. American Osteopathic Association.
Accreditation of Colleges of Osteopathic
Medicine: COM Accreditation Standards
and Procedures. Chicago, IL: American
Osteopathic Association; 2009. Available
at: http://www.do-online.org/pdf/SB03-Stan
dards%20of%20Accreditation%20July%20
2009.pdf. Accessed September 21, 2009.
16. Liaison Committee on Medical Education.
Functions and Structure of a Medical
School – Standards for Accreditation of
Medical Education Programs Leading to
the MD Degree. Washington, DC:
American Medical Association; 2008.
Available at: http://www.lcme.org/
functions2008jun.pdf. Accessed
September 21, 2009.
17. Duke University School of Medicine. About
the Duke Curriculum. (http://medschool.
duke.edu/modules/som_curriculum/index.
php?id=2). Revised 2009. Accessed
September 21, 2009.
18. University of Minnesota Medical School.
Flexible MD. (http://www.meded.umn.edu/
admissions/flex_md.php). Revised 2009 .
Accessed September 21, 2009, 2009.
19. Faculty of Medicine University of Calgary.
Overview of the Curriculum. (http://www.
medicine.ucalgary.ca/mdprogram/
prospective/introduction). Revised 2009.
20. McMaster University Faculty of Health
Sciences. Michael G Degroot School of
Medicine Overview. (http://fhs.mcmaster.
ca/main/medschool.html). Revised 2009 .
21. Lockyer JM, Violato C, Wright BJ, Fidler
HM. An Analysis of Long-Term Outcomes
of the Impact of Curriculum: A Comparison
of the Three- and Four-Year Medical
School Curricula. Acad Med.
2009;84:1342-1347.
22. Flegel KM, Hebert PC, MacDonald N. Is it
time for another medical curriculum
revolution? CMAJ. 2008;178:11.
23. Lake Erie College of Osteopathic
Medicine. LECOM Learning Pathways &
Curriculum. (http://www.lecom.edu/pros_
pathways.php). Revised 2008 . Accessed
September 21, 2009.
24. Bell HS, Ferretti SM, Ortoski RA. A ThreeYear Accelerated Medical School
Curriculum Designed to Encourage and
Facilitate Primary Care Careers. Acad
Med. 2007;82:895-899.
25. Ortoski RA, Keith DS, Haen MA, et al. The
LECOM Primary Scholars Pathway: An
Innovative 3 Year Curricular Design – The
First Class. Erie, PA: 2008. Available at
http://www.aacom.org/events/annualmtg/
past/2009/posters/Documents/Ortoski_PC
SP%20The%20First%20Class.pdf.
May/June 2010 | Vol. 106 35
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General | NEWS
Wheeling Jesuit University Health Center Adopts
Electronic Medical Records
BY TRICIA LOLLINI
The Wheeling Jesuit University
(WJU) Health Center has launched
HEALTHeWV (HeWV), a paperless
records system that gives health
care professionals quick access
to patient information, clinical
practice guidelines and patient
education materials. “Implementing
HEALTHeWV into our university
health center provides a great
opportunity for our collaboration
with Sponsored Programs. This
partnership in turn, will help us
to work better together across the
University - including with faculty
in our health-science programs.
It’s a “win-win” in a lot of ways,”
states Christine Ohl-Gigliotti,
Dean of Student Development.
HeWV, a congressionally
sponsored program brought to
the state through the efforts of
Senator Robert C. Byrd (D-WV) and
managed by the National Technology
Transfer Center (NTTC) at Wheeling
Jesuit University offers health
care providers quick access to the
latest in evidence-based medicine
guidelines and improving patientprovider communication with use
of electronic health surveys and
electronic charting. HeWV goes
beyond a typical electronic medical
record (EMR) system to focus on
patient care and improving patients’
health outcomes. HeWV went
“live” for the first time in 2006 at
Wheeling Health Right. Since then
it has been adopted by 29 additional
clinics. The WJU health center is the
first college campus health center
in the state to adopt the system.
The WJU Health Center is
committed to the mission of Wheeling
Jesuit University to educate young
men and women. It seeks to remove
and reduce health-related barriers
to learning and to encourage each
student to become knowledgeable
in both in prevention of illness and
in responsible self-care. The Health
Center functions as a resource to
provide direct health care through
high quality, comprehensive, costeffective, accessible service to meet
the needs of the individual student.
“We have been working hard
in training for the HEALTHeWV
program and appreciate the time
the HEALTHeWV staff took to help
us prepare for the initiation of the
program. We look forward to the
positive changes and anticipate the
program will provide us with a better
ability to track student health needs”
says Amy Cronin, RN and Nurse
Coordinator at the health center.
The Health Center, in line with
its holistic approach, offers student
counseling services, commits itself
to the principles of health and
well-being and aspires to provide
services which will enhance
emotional health, personal growth,
and interpersonal development.
WJU Vice President for Sponsored
Programs, J. Davitt McAteer, says the
University’s role in the HEALTHeWV
project is an extension of its overall
mission to make a positive difference
in the lives of fellow West Virginians.
“We are proud that Wheeling
Jesuit University is West Virginia’s
first student health center to use
HEALTHeWV. We believe it will
only improve the already efficient
and effective work of the health
center staff as well as further the
already positive experience our
students have at the center.”
With the success of HEALTHeWV,
Senator Byrd says West Virginia
can serve as a model to other
states considering EMR systems.
Clinics interested in more
information about the HeWV
program can contact Melissa Mealy
at (304) 243-4375, mmealy@nttc.
edu or visit www.healthewv.net.
The youngest of 28 Jesuit colleges
and universities in the United States,
Wheeling Jesuit University offers
students a high-quality private
education. Since 1995 U.S. News &
World Report has ranked Wheeling
Jesuit University among the top
institutions in its “Best Master’s
Universities in the South” category.
The campus is home to the Robert
C. Byrd National Technology
Transfer Center, the Erma Ora
Byrd Center for Educational
Technologies and the Clifford M.
Lewis Appalachian Institute.
4/23/20103:10:58PM
Haiti Relief Efforts
Photo montage by Donna Tassos
Inset: photographer Donna Tassos, RN
Medical and ministry staff include: Large photo above, Becky Barido, RN. Top, left to right: Sonal Shah, MD, Rick
Hayes, MD, Rafael Gomez, MD, Aeysha Rahman, MD (holding the baby). Bottom and center, left to right: Pastor Andre Jean,
Lora Hayes, RN, two group photos, Paul Nanda, MD, and Lindsey Clark, RN.
May/June 2010 | Vol. 106 37
4/23/20103:11:00PM
SPECIAL | NEWS
The Fight is on!
Med-Mal Caps Challenge Heads to WV Supreme Court
We’ve been expecting this for several years now since the passage of our comprehensive
medical liability reform legislation (HB 2122) in 2003. A case challenging the non-economic
damages cap was accepted to be heard by the WV Supreme Court of Appeals. Justice
Ketchum was the one dissenting vote. Justice McHugh recused himself because he is
on the Board of Trustees of Thomas Hospital, and Chief Justice Davis replaced him with
Circuit Judge Ronald Wilson. The briefing and oral argument schedule is yet to be set.
On April 15, the WV Supreme Court voted 4-1 to accept the petition for appeal in McDonald
v. City Hospital, Inc. The case involves a Medical Professional Liability Act (MPLA) jury
verdict for the plaintiffs, awarding $1,129,000 to the plaintiff and $500,000 to his wife for
loss of consortium, splitting liability between the doctor (70%) and the hospital (30%).
The award to the plaintiff included $1M in noneconomic damages for past and future pain
and suffering. On post trial motion, Circuit Judge Silver reduced the award to $500,000,
applying the MPLA cap per WV Code § 55-7B-8b which caps noneconomic damages at
$250,000 or $500,000 if there is death or substantial permanent injury. Judge Silver’s ruling
meant the wife’s award was reduced to “0” and the plaintiff’s to $500,000. The plaintiffs
challenged the constitutionality at the circuit court level and pursued the issue on appeal.
The WVSMA is taking this challenge very seriously and we will be gearing up to
engage in this battle to support the position that the noneconomic damages caps are
constitutional and an appropriate exercise of legislative power. The noneconomic
damages “caps” are a critical piece of the 2003 legislation, and maintaining
them is essential to the state’s ability to attract and maintain new doctors.
Now is the time for physicians to stand together.
21% Medicare physician payment cuts stopped until June 1, 2010
On April 15, the Senate and House of
Representatives passed, and the President
signed into law, H.R. 4851 the “Continuing
Extension Act of 2010.” This legislation
reinstated Medicare physician payments to
the March 31 levels, again postponing the 21.3
percent cut that was supposed to take effect
January 2010. This most recent extension of 2009
payment rates will continue through May 31,
and be applied retroactively to all physician
services provided to Medicare patients in April.
The legislation also includes a clarification
to the definition of electronic health records
(EHRs), amending language in the “American
Recovery and Reinvestment Act of 2009” (the
Stimulus Bill) to allow clinic-based physicians
who bill through hospitals to receive bonus
payments for the adoption of EHRs.
4/23/20103:11:01PM
Special | News Continued
Health System Reform and its Impact on West Virginia
President Barack Obama signed the Patient Protection
and Affordable Care Act (H.R. 3590) into law on March
23, 2010. This law is being proclaimed by many to be
the most significant health reform legislation passed by
congress in generations. The monumental bill is expected
to bring down health care costs for American families
and small businesses, expand coverage to millions of
Americans and end bad practices of insurance companies.
So how does this legislation impact West Virginians and
more specifically West Virginia’s practicing physicians?
The information below is a compilation of information obtained
from a variety of sources including the American Medical
Association (www.AMA-Assn.org) and the Department of
Health and Human Services (www.HealthReform.gov).
Under the reform legislation, the Obama
administration at the Department of Health and
Human Services is projecting the following:
• 256,000 West Virginia residents who do not
currently have insurance and 41,000 residents who
have non-group insurance could get affordable
coverage through the health insurance exchange.
• 204,000 West Virginia residents could qualify for premium
tax credits to help them purchase health coverage.
• 372,000 West Virginia seniors would
receive free preventive services.
• 66,000 West Virginia seniors would have
their brand-name drug costs in the Medicare
Part D “doughnut hole” halved.
• 20,000 small West Virginia businesses could
be helped by a small business tax credit to
make premiums more affordable.
There has been a great deal of talk about what this 2,400+
page bill covers and doesn’t. The following is a basic
summary of the core components of the legislation and the
impact on patients, physicians, businesses and insurers.
There are many great sources of information available for
consumers and physicians to find out more on the impact
of this bill. The WVSMA is compiling information into a
one stop shop on our website please visit www.WVSMA.
com for more detailed and up-to-date information.
Many components of the bill immediately go into effect
while others are phased in over the next four years.
What the Bill Does In a Snapshot
• Health insurance coverage is significantly expanded
and competition in the marketplace is improved;
• Pre-existing condition limitations are removed and other
health insurance market reforms are implemented;
• Patient-physician relationship is protected;
• Investments and incentives are provided for quality
improvement, prevention and wellness initiatives; and,
• Insurance claims processing is streamlined
and standardized to eliminate unnecessary
costs and administrative burdens.
Medical Liability Reform
Many have asked the question “what is included in the
bill relating to medical liability reform?” The short answer
is “not much”. There is no liability reform component of
this legislation but the following points are included:
• Does establish a competitive grant program
for states to develop, implement and evaluate
innovative medical malpractice reforms.
• Does extend medical liability protections under the
Federal Tort Claims Act to officers, governing board
members, employees and contractors of free clinics.
• Does authorize a Government Accountability
Office (GAO) study and report on whether the
development or implementation of guidelines,
standards, or payment adjustments (e.g., health
care acquired conditions) specified in multiple
sections of the bill would result in new causes of
action or claims against health care providers.
How the Bill Expands Health Insurance
Coverage
The legislation is projected to expand insurance
coverage to an additional 32 million persons by 2019,
equating to coverage of 59 percent of the uninsured.
The following is a synopsis of the mechanisms
through which this will be accomplished:
1.Expanding Medicaid eligibility to all individuals
under age 65 (including childless adults) up to
133 percent of the federal poverty level (FPL).
•Federal government will cover 100 percent
funding for the expansion of Medicaid coverage
to all individuals from 2014 to 2016, diminishing
to 90 percent in 2020 and thereafter.
• Projected 16 million uninsured Americans
will become covered under Medicaid and the
Children’s Health Insurance Program by 2019.
• The legislation requires Medicaid payment rates
to primary care physicians providing primary
care services be no less than 100% of Medicare
payment rates for 2013 and 2014, and provides
100 percent federal funding for the incremental
costs to states of meeting this requirement.
May/June 2010 | Vol. 106 39
4/23/20103:11:01PM
SPECIAL | NEWS
2. Provides “premium” credits to individuals and families
up to 400 percent of FPL ($88,200 per year for a family
of four) for the purchase of private health insurance.
• Premiums in the small group market (13 percent of
those with insurance coverage) may fall—CBO predicts
a change from -2% to + 1% compared to current law.
3. Provides dependent coverage for children up to
age 26 under all individual and group policies.
• Premiums in the non-group market (17 percent
of those with insurance coverage) are expected to
rise by an estimated 10 to 13%. While premiums
will likely rise in this market, such policies will
contain richer benefits. Additionally 57% of the
non-group enrollees will likely receive a subsidy
making their actual contribution 56 to 59% lower.
4. Requires coverage of children with pre-existing
conditions in 2010 & insurers can’t drop insureds if they
get sick.
5. Establishes a temporary “High Risk Pool” for adults with
pre-existing conditions – until 2014 when all insurers
are required to cover pre-existing conditions for adults.
6. Disallows lifetime financial limits on benefits.
7. Preventive services (mammograms, immunizations)
covered by insurers with no co-payments or deductibles.
8. Medicare patients who hit “doughnut hole” will
receive $250 rebate from Medicare and after 2011
will receive 50% discount on prescription drugs.
9. State based health insurance exchanges will
begin in 2010 for persons without access to
employer-based insurance coverage.
10. In 2011 states can require insurers to justify premium
increases and impose penalties for excess increases.
Requirement for Insurance Coverage
A core component of the success of the reforms is that most
Americans will have some sort of health care coverage.
If coverage isn’t available either through a persons’
employer or by qualifying for government run programs
(Medicaid, CHIP, Medicare) individuals will be required
to purchase coverage. There are various exemptions for
different income levels but basically, by 2014 individuals
will be required to obtain health insurance coverage or
pay a penalty to the government which incrementally
rises over time. That penalty is: $95 in 2014, $325 in 2015,
$695 in 2016 or as a % of income in the amount of 1% in
2014, 2% in 2015, and 2.5% in 2016. After 2016, the penalty
will increase annually by the cost-of-living adjustment.
Impact on Insurance Company Practices
Insurance companies are prohibited from denying
coverage based on pre-existing conditions. Premiums
may not be based on gender and health status. Insurers
may not drop coverage if policyholders get sick,
and once insured, individuals and families will be
guaranteed renewal of their health insurance policies.
Impact on Insurance Premiums for Insured
• Health insurance premiums will not rise for most people.
• The Congressional Budget Office (CBO) predicts
that premiums in the large group market
(nearly 70 percent of the non-elderly covered
population) would drop 0 to 3% in 2019.
Impact on Physician Practices: the Positive
• Physicians will continue to exercise considerable
control over the practice of medicine and the
care that they provide to their patients.
• By covering the uninsured it cuts into the $24 billion
plus annually in charity care provided by physicians.
• The financial impact is particularly acute when private
and public payments are declining or flat, and physicians
are less able to cover the cost of treating uninsured
patients with revenue from insured patients.
• The time and cost burden of physicians’ practices
interactions with health plans is large. Administrative
simplification provisions will reduce these costs.
Physicians spend on average about 140 hours and
$68,000 a year just dealing with health insurance
bureaucracy. The Obama Administration estimates
this adds up to 754,200 hours and $366 million in
costs to West Virginia physicians. By simplifying and
standardizing paperwork and computerizing medical
records, doctors will be able to focus on caring for
their patients instead of dealing with bureaucracy.
• Many payment improvements are included
in the legislation that when combined will
result in immediate and significant Medicare
payment increases for many physicians.
o 10 % incentive payments for primary care physicians.
o 10 % incentive payments for general
surgeons performing major surgery in
health professional shortage areas.
o 5 % incentive payment for mental health services.
o Medicare quality reporting incentive payments
extended. Incentive payments of 1 percent
in 2011 and 0.5 percent from 2012–2014 will
continue for voluntary participation in Medicare’s
Physician Quality Reporting Initiative (PQRI).
o Administrative simplification - national rules
are to be implemented between 2013-2016 to
standardize and streamline claims processing.
Impact on Physician Practices: the Negative
• Value index adjustments to individual physician
payments based on cost and quality outcomes by 2015.
4/23/20103:11:02PM
SPECIAL | News Continued
• Potential penalties on physicians who do not
successfully participate in the Physician Quality
Reporting Initiative (PQRI) by 2015.
• Public reporting of physician claims data
to develop performance reports.
• Independent Payment Advisory Board (IPAB) to develop
proposals to cut Medicare spending if the target rate
of growth is exceeded. The Secretary of HHS required
to implement the proposals unless a statutory override
(Projected cuts would total $13 billion over 10 years.)
• Utilization assumption for high-cost imaging
equipment will be increased to 75 percent effective
Jan. 1, 2011 (Net cuts $2.3 billion over 10 years).
• New physician-owned hospitals will be banned
from participating in Medicare and limits are
placed on growth of existing physician-owned
facilities (net cuts $500 million over 10 years).
Impact on the States
State budgets are expected to be relieved from rising health
care costs as reform:
Reduces state employee premiums: Coverage would
immediately be expanded to the uninsured, decreasing the
amount of uncompensated care costs that gets shifted to
the premiums of state employees. For states that provide
early retiree health benefits to their state employees, a
reinsurance program would provide premium relief of up
to $1,200 per family policy per year for all employees.
Reduces uncompensated care: The Obama Administration
estimates that West Virginia providers lose $482 million in
uncompensated care each year, which states subsidize at
least in part. Under the reform, uncompensated care would
begin to be reduced immediately as more uninsured people
gain coverage.
Invests in the health care workforce: The Obama Administration
estimates approximately 169,000 people, or 9 percent of West
Virginia’s population, cannot access a primary care provider
due to shortages in their communities. Health insurance
reform will expand and improve programs to increase the
number of health care providers, including doctors, nurses,
and dentists, especially in rural and other underserved areas.
Impact on Employers
Small Business Tax Credit: Businesses with 50 or less
employees which contribute at least 50 percent of the total
premium cost of their employees, who have average annual
wages below $50,000 will be eligible for the tax credits of
up to 35 percent (for tax years 2010-2013) of the premium
paid for their employees. The credit phases out as firm size
and average wage increase. In tax years 2014 and later,
for eligible small businesses purchasing coverage through
the state exchanges, the tax credit increases to 50 percent
of the employer’s contribution toward the premium.
According to the IRS, the wages and hours of physician business
owners and partners will not be counted in calculating either the
number of full-time employees or the average annual wages.
Large Businesses would have no “employer mandate” but “employer
responsibility”: Businesses with more than 50 employees which
do not offer health insurance to their employees must
reimburse the government for subsidies provided to their
employees who use the exchange to purchase health
insurance. The penalty amounts to $2,000 multiplied by the
number of full-time employees in excess of 30.
40 percent excise tax (“Cadillac” tax) on high-cost health plans:
Beginning in 2018, an excise tax will be imposed on the
coverage provider (i.e., insurer, plan administrator or
employer depending on the type of coverage) of high-cost
employer-sponsored health plans with aggregate values
exceeding $10,200 for individual coverage and $27,500
for family coverage. The tax is equal to 40 percent of the
value of the plan that exceeds these threshold amounts.
Expenses allocable to Medicare Part D subsidy: Effective 2013,
employers that currently sponsor retiree prescription
drug plans will no longer be able to deduct amounts
contributed to them. However, future Medicare Part D
subsidies will continue to be tax-free to the employer.
Limitation on excessive health insurance company compensation:
Effective 2013, the deduction for executive and employee
compensation for health insurance providers is limited
to $500,000 per applicable individual. The limit applies
to all officers, employees, directors and other workers.
Taxes and Credits
Annual fee on health insurance providers: Beginning in
2014, a fee will be applied on net premiums of all health
insurers based on their market share. For non-profit
insurers, only 50 percent of net premiums will be taken into
account in calculating the fee. Exemptions are granted.
Annual fee on pharmaceutical companies and medical device
manufacturers: New annual fees on certain manufacturers
and importers of branded prescription drugs (including
biological products, but excluding orphan drugs) would
be imposed beginning in 2011 based on annual sales and
set to reach a certain revenue target each year. Beginning
in 2013, an annual excise tax of 2.3 percent will also
be imposed on the sale of Class I medical devices by
manufacturers, producers or importers. Class I includes
the vast majority of orthotics and prosthetics, as well as
durable medical equipment. Exemptions are provided for
eyeglasses, contact lenses, hearing aids and any device
that is generally purchased at retail for individual use.
Excise tax on indoor tanning services: Effective July 1,
2010, an excise tax of 10 percent will be imposed on
the amount paid for indoor tanning services.
May/June 2010 | Vol. 106 41
4/23/20103:11:02PM
WESPAC Contributors | WESPAC is the West Virginia State Medical Association’s bipartisan political action committee. We
work throughout the year with elected officials to make sure they understand the many facets of our
healthcare system.
WESPAC’s goal is to organize the physician community into a powerful voice for quality healthcare in
the West Virginia Legislature. We seek to preserve the vital relationship between you and your patients by educating our legislators about issues
important to our physicians.
WESPAC contributions provide critical support for our endorsed candidates. Your contribution can make the difference between a pro-physician/
patient candidate winning or losing.
To make a contribution to WESPAC, please call Amy Tolliver at (304) 925-0342, ext. 25
2010 WESPAC Contributors
The WVSMA would like to thank the following physicians, residents, medical students and Alliance
members for their 2010 contributions to WESPAC. These contributions were received as of April 19:
Chairman’s Club ($1000)
Patrick P. Dugan, MD
Dana Olson, MD
Extra Miler ($500)
David A. Bowman, MD
James L. Comerci, MD
Generoso D. Duremdes, MD
Michael A. Kelly, MD
Michael A. Stewart, MD
Dollar-A-Day ($365)
Greenbrier D. Almond, MD
Edward F. Arnett, MD
D’Ann E. Duesterhoeft, MD
Michael O. Fidler, MD
William L. Harris, MD
Sushil K. Mehrotra, MD
Stephen R. Powell, MD
L. Blair Thrush, MD
John A. Wade, Jr., MD
Mark D. White, MD
Campaigner Plus (> $100)
Kenneth J. Allen, MD
Kamalesh Patel, MD
Finbar G. Powderly, MD
Richard A. Rashid, MD
Syed M. Siddiqi, MD
Diane E. Shafer, MD
Campaigner ($100)
Moutassem B. Ayoubi, MD
Rano S. Bofill, MD
William H. Carter, MD
Patsy P. Cipoletti, MD
W. Alva Deardorff, MD
John E. Dudich, MD
Ruperto D. Dumapit Jr., MD
James D. Felsen, MD
Robert T. Linger Sr., MD
Nancy N. Lohuis, MD
Ignacio H. Luna, Jr, MD
Harry A. Marinakis, MD
Stephen K. Milroy, MD
Fred T. Pulido, MD
Wayne Spiggle, MD
Wilfredo A. Tiu, MD
Byron L. Van Pelt, MD
Ophas Vongxaiburana, MD
Syed A. Zahir, MD
Donor
Luis A. Almase, MD
Lynn Comerci,
Kathleen Mimnagh, MD
Important
READ!
The WESPAC Board currently has vacancies for which we are soliciting nominations. If you know someone who would be a
great addition to the Board please contact our Director Amy N. Tolliver, MS at [email protected] or (304) 925-0342. Self
nominations are encouraged.
WESPAC Board Members
2010-2011
STATE AT-LARGE - 2 SEATS
Phillip R. Stevens, MD, Chairman
M. Tony Kelly, MD
WVSMA COUNCIL REPRESENTATIVE - 1 SEAT
F. Tom Sporck, MD, Secretary
FIRST CONGRESSIONAL DISTRICT - 2 SEATS
Ken Nanners, MD
David W. Avery, MD
SECOND CONGRESSIONAL DISTRICT - 2 SEATS
John Wade, MD
Other seat vacant
THIRD CONGRESSIONAL DISTRICT - 2 SEATS
Ahmed D. Faheem, MD
Other seat vacant
ALLIANCE REPRESENTATIVE - 1 SEAT
Terry Waxman
DIRECTOR
Amy N. Tolliver, MS, Treasurer
4/23/20103:11:03PM
WESPAC 2010 Primary Election Endorsements
The following are the WESPAC endorsements for the 2010 Primary Election. Please tear out this page and take it to the polls on Election
Day, Tuesday, May 11th.
WESPAC endorses healthcare friendly candidates who will promote initiatives supported by the WVSMA and the physician community.
WESPAC is a voluntary, bipartisan, unincorporated organization composed of physicians, residents medical students and their spouses and
is a separate segregated fund established by the West Virginia State Medical Association (WVSMA).
Federal and Statewide Offices
District Party
1
D
2
R
Name
Mike Oliverio
Shelley Moore Capito
District Party
1
D
2
D
4
R
5
D
7
D
8
D
10
R
Name
Dan Greathouse
Larry J. Edgell
Mike Hall
Evan H. Jenkins
Ron Stollings
Erik Wells
Rick Romeo
District Party
2
D
2
D
3
R
4
D
4
D
5
D
6
R
7
R
8
R
9
R
10
R
10
R
10
R
10
R
11
R
12
R
14
R
14
R
15
D
15
D
15
R
16
R
17
D
17
D
18
D
19
D
19
D
19
D
20
D
21
D
25
R
26
D
27
D
District Party
3
D
3
R
State Senate
County
Hancock
Wetzel
Putnam
Cabell
Boone
Kanawha
Greenbrier
District Party
11
D
12
D
14
R
15
D
16
D
17
D
Name
Nick Joe Rahall II
Elliott E. “Spike” Maynard
Name
Gregory A. Tucker
Joseph M. (Joe) Minard
Dave Sypolt
Walt Helmick
John Unger
Brooks McCabe
House of Delegates
Name
Tim Ennis
Roy E. Givens
Dolph Santorine
Michael T. Ferro
Scott G. Varner
Dave Pethtel
Wm. Roger Romine
Lynwood “Woody” Ireland
E.W. “Bill” Anderson Jr.
Larry Border
Tom Azinger
Frederick David Gillespie, MD
Denny Harton
Eric Jiles
Bob Ashley
Mitch B. Carmichael
Troy Andes
Debra Girimont
Kevin J. Craig
Jim Morgan
Carol Miller
Kelli Sobonya
Don Perdue
Richard Thompson
Larry W. Barker
Rupert “Rupie” Phillips Jr.
Josh Stowers
Teddy “Ted” Tomblin
K. Steven Kominar
Harry Keith White
T. Mike Porter
Gerald L. Crosier
Virginia Mahan
County
Brooke
Brooke
Ohio
Marshall
Marshall
Wetzel
Tyler
Ritchie
Wood
Wood
Wood
Wood
Wood
Wood
Roane
Jackson
Putnam
Putnam
Cabell
Cabell
Cabell
Cabell
Wayne
Wayne
Boone
Logan
Lincoln
Logan
Mingo
Mingo
Mercer
Monroe
Summers
District Party
27
D
27
R
27
R
28
D
28
R
29
D
29
D
30
D
30
D
30
D
30
R
30
R
30
R
30
R
32
R
32
R
34
D
36
D
37
D
37
D
39
R
41
D
41
D
44
D
44
D
44
R
45
D
47
D
48
R
51
R
54
R
55
R
57
D
Name
William R. “Bill” Wooton
John David O’Neal IV
Linda Sumner
Thomas W. Campbell
Ray Canterbury
David Perry
John Pino
Barbara “Bobbie” Hatfield
Doug Skaff Jr.
Sharon Spencer
Brian F. Hicks
Fred Joseph
Eric Nelson
Jim Strawn
Tim Armstead
Patrick Lane
Brent Boggs
Joe Talbott
Bill Hartman
Robbie Morris
Tom O’Neill
Samuel J. “Sam” Cann
Tim Miley
Barbara Evans Fleischauer
Charlene Marshall
Amanda Pasdon
Larry A. Williams
Harold Michael
Allen V. Evans
Daryl E. Cowles
Walter E. Duke
John Overington
John Doyle
County
Nicholas
Harrison
Preston
Pocahontas
Berkeley
Kanawha
County
Raleigh
Raleigh
Raleigh
Greenbrier
Greenbrier
Fayette
Fayette
Kanawha
Kanawha
Kanawha
Kanawha
Kanawha
Kanawha
Kanawha
Kanawha
Kanawha
Braxton
Webster
Randolph
Randolph
Upshur
Harrison
Harrison
Monongalia
Monongalia
Monongalia
Preston
Hardy
Grant
Morgan
Berkeley
Berkeley
Jefferson
May/June 2010 | Vol. 106 43
4/23/20103:11:04PM
Legislative | NEWS
2010 Legislative Session Wrap Up
At midnight on Saturday March 13 the WV
Legislature adjourned calling an end to the 2010
Legislative Session. As usual they continued meeting
on a limited scale the following week to focus
on the final passage of the State budget bill.
For physicians this was a pivotal legislative year. The
focus on scope of practice and the legislatures’ certain
interest in passing legislation for the optometrists against
the objections of the physicians, hospitals, others in the
medical community and even the AARP, sent a direct
message that we should be concerned about the success
of such attempts by other special interests next year.
There was a plethora of other bills introduced
this Session which aimed to grant scope of practice
expansions to the nurses, pharmacists and the
radiologist assistants. Most of the bills didn’t gain
much support and none passed. However, it very
well may be a different story in the coming years.
It is evident nationally that nearly all allied health
professional groups are vying for scope expansions.
This will continue to be a top priority of the WVSMA.
The following is a summary of key issues
addressed during the 2010 legislative Session.
For a quick look at all bills, you can visit the
legislative website at www.legis.state.wv.us
Medical Liability Law Safe for Another Year
The WVSMA is always looking out for bills that
might take a bite out of our hard fought medical liability
reforms. This Session was a good one on this front where
no bills were addressed which would have weakened
our reforms. The pharmacists did try to get a bill passed
(SB 8) which would have clarified they are considered a
healthcare provider under the medical professional liability
act and thus protected by the caps and other measures.
This legislation did pass the Senate but did not make it
onto the agenda of the House Judiciary Committee.
Provider Tax Phase out on Home Stretch
After a long ten-year phase out of the health care
provider tax, on July 1, 2010 physicians, chiropractors,
dentists, nurses (RN’s & LPN’s), opticians, optometrists,
podiatrists, psychologists and therapists (PT’s & Massage)
will no longer pay the provider tax in West Virginia!
This is a monumental success which all physicians
should celebrate. Over the past few years while the West
Virginia tax has been phasing out, other states have
actually been looking to implement new provider taxes
in order to shore up the state budgets. Sound familiar?
Optometrists Expand Scope of Practice: Lose battle
on Laser Surgery and “Physician” Designation
The Legislature adjourned at midnight on Saturday and
about an hour before passed SB 230 the optometry scope
expansion bill.
A big THANK YOU to all who engaged on the effort
to weaken the bill. Over 350 emails were sent to members
of the Legislature through the use of our advocacy system
and numerous phone calls were made. The engagement of
physicians, both ophthalmologists and all other specialties
was critical to this effort and really made a positive impact.
The two biggest concerns with the bill were absent
from the final draft - laser surgery and the use of
the term “optometric physician”. On the laser issue
medicine succeeded in getting language in the bill
that specifically states an optometric licensee “may
not use a therapeutic laser”. On the optometric
physician issue their statute is still silent - the bill did
not address the issue. So these were two huge wins!
That’s not to say that they didn’t get a lot - which they
did. The final bill is bad but is truly as good as we could
get it this year. The following is a summary of the bill:
•Allows use of epi-pens, additional injections must
be defined by Board of Optometry and approved
through the Legislative Rule-making process. There is
a prohibition from injecting into the globe of the eye;
•Allows prescribing and dispensing of contact lenses that
contain and deliver pharmaceutical agents that have
been approved by the Food and Drug Administration
as a drug. (this was actually pushed by Johnson &
Johnson, these contacts are not on the market yet);
•Allows the Board of Optometry to add new drugs and
new drug indications to their drug formulary without
going through the Legislative Rule-making process;
•Allows optometrists to order laboratory tests
rational to the examination, diagnosis, and
treatment of a disease or condition of the eye;
•Allows optometrists to perform the following surgical
procedures and allows the board to determine
through Legislative rule additional procedures:
emove a foreign body from the ocular surface
o R
and adnexa utilizing a non-intrusive method;
o R
emove a foreign body, external eye, conjunctival,
superficial, using topical anesthesia;
o R
emove embedded foreign bodies or
concretions from conjunctiva, using topical
anesthesia, not involving sclera;
4/23/20103:11:05PM
Legislative | News Continued
o R
emove corneal foreign body not through to the
second layer of the cornea using topical anesthesia;
o Epilation of lashes by forceps;
o Closure of punctum by plug;
o D
ilation of the lacrimal puncta
with or without irrigation;
•Allows Optometry board through the Legislative
Rule-making process to issue the requirements for
an expanded scope of practice for those procedures
“taught” at 50% of all accredited optometry schools.
The legislative rule-making process requires a board
to file their rule with the Secretary of State (SOS) and
allow a 30 day public comment period (which happens
mid-summer). Then the board must respond to each
comment/recommendation made and re-file the rule
(either modified or not) with the SOS. Then the rule
goes through a first layer of legislative scrutiny through
the Legislative Rule-making Review Committee. That
committee may modify the rule, then the rule is finally
introduced into the legislative system as a bill (in January)
that must go through the entire legislative process like
any other bill and may be amended in any committee.
Credentialing Process to Become Streamlined
After two years of review by stakeholder groups and
the Insurance Commissioner’s Office, the Legislature has
passed legislation aimed at simplifying the credentialing
process for physicians and other healthcare providers.
HB 4176 directs the Insurance Commissioner’s Office,
through the Credentialing Committee to begin work
on developing legislative rules for contracting with a
single Credentials Verification Organization (CVO). This
CVO would be responsible for verifying the credentials
for providers then disseminating that information to
the entities (insurers, hospitals) which credential those
providers. It is expected that through this process and
timelines for credentialing which are also included
in the bill will simplify the credentialing process for
physicians and will shorten the duration of time.
The Credentialing Committee has until June of
2011 to finalize the rules for the CVO and then the
Legislature must approve those rules before the
Insurance Commissioner’s Office may move forward
on contracting with an entity. This is the beginning of a
long process that should prove to be very beneficial. The
following are the basic components of this legislation:
•The bill allows the Insurance Commission to enter into
contract with a company to perform credentials
verification for all practitioners who require
credentialing;
•This company will be established as the one credentialing
verification organization (CVO) in the state which all
insurers and hospitals (any entity which credentials
practitioners) must use for credentials verification;
•It will streamline the credentialing process and enable
credentialing of physicians in a more timely manner;
•The bill establishes timelines that the CVO,
Insurers, and practitioners must meet to perform
their credentialing functions and decisions;
•Payment to the physician is retroactive to the date
verified credentials are given to the insurer.
Bills Address “Doctor Shopping”, Substance Abuse
With the increasing concern with controlled substance
abuse issues in West Virginia the legislature has been
looking at finding ways to focus their attention on
addressing the problem. However, finding the silver
bullet solution to this problem has evaded most.
Senators Evan Jenkins and Ron Stollings took a stab
at the problem and proposed a list of about eight
bills addressing various components of the issue. The
following is a summary of the bills that passed:
SB 365 - Requiring pharmacies provide personnel online
access to controlled substances database.
It was discovered that some of the largest and
busiest pharmacies in the state (including WalMart)
had policies which hampered the pharmacists’ ability
to utilize the best tool in fighting doctor shopping.
Pharmacists did not have access to the Controlled
Substances Monitoring Database. This bill requires all
prescribers and dispensers of controlled substances (it
does apply to physicians) to have “electronic” access to
the database. The Board of Pharmacy is responsible for
developing rules to implement the law. The WVSMA will
keep our members apprised of the developing rules.
Additionally included in this bill is a provision that
clarifies the State Medical Examiner’s Office may have
access to the database for use in post-mortem examinations.
SB 81 – Creating WV Official Prescription Program Act
This bill requires the Board of Pharmacy to
establish a rule implementing a statewide tamperresistant prescription paper program. The paper will
be required to be used for all prescriptions (currently
just Medicaid requires tamer resistant paper) and
the board is responsible for approving the safety
features that must be included in the paper and
establishing the approved vendors. Additionally they
will develop a tracking method (i.e. numbering of
prescriptions) to ensure prescriptions are valid.
May/June 2010 | Vol. 106 45
4/23/20103:11:07PM
Legislative | NEWS
SB 362 – Prohibiting providing false information to
obtain controlled substances prescription
The bill clarifies the current law regarding doctor
shopping. It modifies the language to clarify that “it
is unlawful for a patient, in an attempt to obtain a
prescription for a controlled substance, to knowingly
withhold information from a practitioner that the patient
has obtained a prescription for a controlled substance of the
same or similar therapeutic use in a concurrent time period
from another practitioner.” It is currently a misdemeanor
to violate this law. The bill raises the penalty from six to
nine months in jail and raises the fine from $1,000 to $2,500.
SB 514 – Clarifying language in Controlled Substances
Monitoring Act
This bill clarifies all dispensers of schedule II-IV
(including physicians) must report to the Controlled
Substances Monitoring Database. There was an
error in the current statute that failed to include
the requirement for reporting the dispensing of
schedule III and IV drugs. This law does apply to
physicians who dispense such medication in office.
Board of Medicine and Osteopathic Medicine
increase Licensure Fees: Medical Professional
Health Program Funded
Both the Board of Medicine and the Board of
Osteopathic Medicine have modified their physician
licensure fee rules under HB 4108. The Board of Medicine
biannual licensure fee will increase from $300 to $400
effective this June. Additionally the Board of Osteopathic
Medicine biannual physician licensure fee will increase
from $200 to $400. Both boards are allocating a portion
of the increased fee to fund the Medical Professional
Health Program which is responsible for monitoring
physicians with mental health or substance use disorders.
The Board of Osteopathic Medicine has a
larger increase partly due to the new staffing
expenses and the additional costs incurred from relocating the office to Charleston this past fall.
Other bills which passed that relate to either board:
SB 372 – Updating language in the Medical Practice Act
This bill makes updates to the code relating
to the Board’s duties and officers. Clarifies
definition of “surgery” includes use of lasers.
SB 618 – Relating to osteopathic physician assistants
This bill makes updates to the code relating
to PA’s. Updates “certificate” to “license”.
Women’s Right to Know Act Modified: Physician
Penalties Removed
The WV Right to Life group pushed hard this Session
for legislation (SB 597) to require women seeking an
abortion to view an ultrasound prior to the procedure.
Many obstetric physicians raised concerns about the bill
and the ambiguity about when the ultrasound would have
to be provided and by which providers. The legislation was
ultimately totally re-written to simply require information
be provided to the patient which informed her of her
option to view an ultrasound image if she so wishes.
As this legislation was being debated in both
the Senate and House, the issue of the penalties to
physicians in current law kept resurfacing. Ultimately
all physician penalties (which included loss of
license for failure to provide written information
to the patient) were removed from the law.
Other Bills of Interest Which Passed
All bills may be accessed by visiting the legislative
website at www.legis.state.wv.us.
SB 122 Increasing mental health treatment refusal age of
consent
This bill raised the age of refusal from twelve to
eighteen. The bill was vetoed by the governor due to
constitutional conflicts.
SB 213 Budget Bill
This bill contains the provisions of state budget for fiscal
year 2011
SB 422 Limiting liability for non-health care provider
defibrillator users
This bill limits liability for good Samaritans
who help out in an emergency.
SB 449 Relating to PEIA preexisting conditions
limitations
SB 483 Authorizing HMOs offer point of service option
The bill allows HMOs to offer point of service
options to enrollees so they may access physicians
out of network in certain instances.
SB 665 Transferring certain Health Care Authority’s
duties to Insurance Commissioner
HB 2485 Allowing pharmacy interns to vend
pseudoephedrine and other chemical precursors of
methamphetamine
The bill clarifies those pharmacy employees who may
sell pseudoephedrine. It simply addresses an oversight
in the current statute that didn’t list all the pharmacy
employees who might be involved in the sale.
4/23/20103:11:08PM
Legislative | News Continued
HB 2503 Requiring licensed tattoo artist to inform
patrons, prior to performing the tattoo procedure,
of the potential problems that a tattoo may cause in
relation to the reading of magnetic resonance imaging
insurance coverage previously by removing the
requirement that children may not be covered if they
have had insurance in the prior twelve months.
HB 4425 Developing a pilot program for unlicensed
personnel to administer medication in a nursing home
The DHHR is responsible for developing the information
to be shared by the tattoo artists.
The bill authorizes the RN Board and Health Care
Association (nursing homes) to develop education
and training standards for the Med Aide program.
The standards would be reviewed by the Legislature
when completed, then a pilot bill would authorize
implementation of the program in early 2011.
HB 2773 Increasing the monetary penalties for selling
tobacco products to minors
The bill increases the fines to persons who sell tobacco
products to minors and clarifies that an employee may be
discharged for violating the act.
HB 4531 Mandating that shackling of pregnant
women who are incarcerated is not allowed except in
extraordinary circumstances
HB 4273 Relating to professional employer
organizations
The purpose of this bill is to authorize the Insurance
Commissioner to apply the same enforcement provisions
to unlicensed professional employer organizations
(PEOs) as are applicable to unauthorized insurers
and to allow the fraud unit to investigate PEOs.
The bill clarifies that incarcerated pregnant women
may not be shackled unless they pose a risk to themselves,
someone else or their baby. The physician must authorize.
Division of Corrections officials say this is no longer done
but the code needed to clarify the practice is banned.
HB 4373 Eliminating the twelve-month
look-back period for certain children who
have had employer sponsored insurance
The bill gives the WV CHIP board the authority
to determine eligibility of children who have had
OFFICE MANAGERS ASSOCIOFFICE
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We invite you to join our organization which consists of members
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Tammy Mitchell
(Membership)
at 304-324-2703. or Donna Lee - State VP
Visit us on our website for more
information or contact
Membership at 276-322-5732.
Donna Zahn (President) at 740-283-4770 ext. 105 or
Tammy Mitchell (Membership) at 304-324-2703.
May/June 2010 | Vol. 106 47
4/23/20103:11:10PM
Robert C. Byrd Health Sciences Center of West Virginia University | NEWS
More than Half WVU Med School Grads Match
to Primary Care Residencies
More than half of the WVU School
of Medicine Class of 2010 will train in
primary health care fields and about
39 percent of all graduates will stay
in the state for their residencies.
The class learned where they
will continue training at Match Day
luncheons at all three medical school
locations in Morgantown, Charleston
and Martinsburg in March.
Students will work in 23 different
fields of study. More than half chose
internal medicine, pediatrics, family
medicine, or obstetrics/gynecology.
Other popular fields this year were
anesthesia, psychiatry, orthopaedics,
emergency medicine and surgery.
Two thirds will stay either in
West Virginia or go to a border
state for their training.
The upcoming academic year
marks the 50th anniversary of WVU’s
Graduate Medical Education (GME)
program. WVU has the largest
number of GME offerings in the
state, with more than 50 specialty
training programs, all of which
are fully accredited. One-half of
these are the only such specialty
programs offered in the state.
(From left to right) Dr. Nate Bailey, Kelly Bailey,
Allison Lowe, Ryan Wakim and Liza LaGue celebrate
Match Day.
WVU School of Medicine in Top 10 for Rural Medicine
The West Virginia University
School of Medicine has been
named one of the top ten schools
of medicine in the country for rural
medicine. WVU made the top ten
list for the second time in U.S. News
& World Report’s 2011 edition of
“America’s Best Graduate Schools.”
The rankings are based on ratings
by medical school deans and senior
faculty in the nation’s 125 accredited
medical schools and 20 accredited
schools of osteopathic medicine.
The School of Medicine also was
listed in the top 50 for primary care.
School of Medicine students at
WVU learn and care for patients
in rural areas of West Virginia
as part of the requirements for
graduation. They work in partnership
with rural communities and with
other health care providers in
rural clinics across the state.
About half of WVU School of
Medicine graduates choose to
practice in primary care areas, such as
family medicine, internal medicine,
emergency medicine, and pediatrics.
The number of physicians who
practice in rural, underserved
communities has increased by
200 percent in recent years.
Akkary Uses SILS at Ruby Memorial Hospital
Ehab Akkary,
M.D., director
of bariatrics
and advanced
laparoscopic
surgery at West
Virginia University,
is providing what
Akkary
he calls the “most
minimally invasive of minimally
invasive surgeries” – single-incision
laparoscopic surgery (SILS).
Traditional laparoscopic
procedures require a minimum
of three small incisions. With the
SILS procedure, a single incision
is made inside the belly button
and is used as the access point for
all needed equipment. Because of
the location of the incision, any
scar that occurs as a result of the
procedure is completely hidden.
Dr. Akkary began performing SILS
procedures in the summer of 2009.
WVU was one of the few institutions
across the nation that adopted
this unique approach early on.
Most of the SILS surgeries
Akkary performs are gall bladder
and appendix procedures. To date,
he has done about 50 of those cases
using SILS. “This approach can be
implemented selectively in various
abdominal operations, including
weight loss surgeries,” he said.
Akkary advises that the SILS
procedure does take slightly longer
than traditional laparoscopic surgery.
There is also no significant decrease
in post-surgical pain or recovery time.
However, for those who are concerned
about multiple incisions and scars,
this procedure may be the answer.
“This is the natural evolution in
advanced laparoscopic surgery,”
Akkary said.
For more information on minimally
invasive surgery at WVU see
http://www.hsc.wvu.edu/som/
Surgery/MinimallyInvasive.
4/23/20103:11:10PM
Marshall University Joan C. Edwards School of Medicine | NEWS
MU’s Chapmanville Center to Provide Care, Teaching
Marshall University and the
Chapmanville community broke
ground April 2 on a new Rural
Health & Clinical Education Center
that will expand both health
care services and career training
opportunities in the region.
The new facility, which will
be the permanent home of
Chapmanville’s Coalfield Health
Center, was made possible by $2.73
million secured by United States
Sen. Robert C. Byrd and a strong
collaboration among community
leaders, the Logan Healthcare
Foundation and Marshall’s Robert
C. Byrd Center for Rural Health.
“When Marshall University officials
approached me about funding this
project several years ago, it was an
easy decision,” Byrd said in a letter
read during the groundbreaking.
“For years I have worked diligently
to improve health care infrastructure
throughout West Virginia, and it was
clear to me that this health care project
had the potential to make a lasting
difference in improving the wellbeing
of the residents of this region.”
Senate President-Lieutenant
Governor Earl Ray Tomblin was the
keynote speaker. The program also
included Roger McGrew, chairman
of the Logan Healthcare Foundation;
Dr. Charles McKown, vice president
and dean of the medical school,
and MU President Stephen J. Kopp,
Ph.D. Congressman Nick J. Rahall
and state senator Ron Stollings,
M.D., spoke briefly as well.
In addition to the expanded health
care it provides, the new center will
offer educational opportunities that
will yield long-term benefits for
the region, said Jennifer Plymale,
an assistant dean at Marshall’s
medical school and the director
of its Center for Rural Health.
“Creating this hub for a rural
teaching center will draw students
New center will become the home of Chapmanville’s Coalfield Health Center and serve as a training site for health
professions students ranging from the undergraduate level through residency.
from many health disciplines
to the heart of the coalfields for
education, and that significantly
increases the possibility of recruiting
healthcare providers to this area
and retaining them,” Plymale said.
Tomblin, who worked to develop
the infrastructure essential for
the center’s success, said before
the event the facility will benefit
the area economically as well.
“Not only will the center provide
much-needed primary care services
for the area, but it will also serve as
an economic development engine for
the area with jobs, a new high-tech
facility, and cooperative partnerships
with businesses, higher education and
other providers in the area,” he said.
On the first floor, the new center
will have a family medicine and
pediatrics clinic, complete with
satellite X-ray and blood-draw/
laboratory facilities. Later, specialty
clinics will occupy the second floor,
providing permanent or rotating
services. The center will incorporate
support spaces needed for training
medical students and resident
physicians, as well as students
training in other health professions.
Electronic linkages will give the
Chapmanville center’s staff and
students access to the extensive
education, research and public
service programs of Marshall’s
Center for Rural Health and medical
school. The new facility also will be
a satellite location for the Center for
Rural Health’s mobile medical unit,
which provides health screening,
education and direct service programs
throughout southern West Virginia.
The Logan Healthcare Foundation
provided the site at no cost
and has made a direct grant of
$180,000 for operating and start-up
assistance, and Marshall’s Center
for Rural Health has committed
$150,000 in start-up support.
As Sen. Ron Stollings looks on, Dr. Charles McKown,
Robert McGrew, Jennifer Plymale, Sen. Earl Ray Tomblin
and Dr. Stephen Kopp break ground for new center.
May/June, 2010, Vol. 106 49
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West Virginia School of Osteopathic Medicine | NEWS
Dr. Robert Holstein to Lead WVSOM Alumni Association
Dr. Robert
Holstein, a
1979 graduate
of the West
Virginia School
of Osteopathic
Holstein
Medicine
(WVSOM),
was elected president of the
WVSOM Alumni Association at
the Association’s annual winter
meeting in Charleston, WV, last
month. The Charleston native
will serve a two-year term.
“I will serve honorably and
diligently alongside a most dedicated
Board of Directors,” Holstein said.
“Together, we plan to continue
to advance the mission of the
Alumni Association in supporting
WVSOM and its students, faculty,
administrative staff and graduates.”
“We are proud of our WVSOM
family and desire to keep alive
the distinctiveness of our school
and profession by adhering
to the foundational principles
of those who preceded us and
who have sacrificed so much to
assure our success,” he said.
A board certified family medicine
physician in Inverness, Fla., Holstein
received a Bachelor of Arts degree
from Anderson University, Anderson,
Ind. in 1974. He is a 1970 graduate of
Dunbar High School in Charleston.
He and his wife, Jean Casey
Holstein, have two children, Stacy
and Scott.
WVSOM Alumni Association Grant to Fund Anatomy Video
Three third-year medical students
plan to use a grant from the West
Virginia School of Osteopathic
Medicine (WVSOM) Alumni
Association to enhance the teaching of
Anatomy at the Lewisburg school.
Students Matt Cauchi, Nathan
Mullins and Sarah Shaw – Graduate
Teaching Assistants (GTA) for the
Anatomy Department – will use the
$3,500 grant to produce a Gross
Anatomy dissection video series.
The students hope to have the first
set of videos available by the
beginning of the 2010-2011 academic
school year.
“The grant will allow us to
purchase additional computer
equipment and software needed to
complete the project,” said Cauchi.
“We have produced approximately
six hours worth of dissection videos
so far, and hope to tape another 10
hours or more this semester.”
In addition to assisting first-year
students with the Anatomy course,
Cauchi said he expects the videos to
be used by second-year students in
reviewing material for the COMLEX I
Board Examination.
Cauchi, Mullins and Shaw wrote
and submitted the grant with the help
of Anatomy professors Dr. Jandy
Hanna and Dr. Christine Eckel. The
WVSOM Alumni Association
reviewed and awarded the grant.
WVSOM Talent Show Proceeds Given to Community Groups
West Virginia School of
Osteopathic Medicine students raised
approximately $3,000 for community
organizations during the 14th annual
Follies Talent Show at Carnegie Hall
March 6.
Organizers said $2,000 will be
donated to the performing arts in
Lewisburg (Trillium, Greenbrier
Valley Theater and Carnegie Hall)
while $1,000 will go to Communities
in Schools of Greenbrier County.
“The Follies is another example of
our students’ commitment to
supporting the community while
showcasing their talents in music,
dance, comedy and other gifts,”
Dr. Meg McKeon, assistant vice
president for Student Development,
said.
McKeon said WVSOM students
provide thousands of hours of direct
volunteer service to the citizens of
Greenbrier County every year, and
stage fundraisers that result in
significant donations to local
organizations.
“The amount of support our
students provide to the Greenbrier
Valley – while maintaining a very
demanding academic schedule –
makes WVSOM unique in academic
circles,” she said. “I am very proud
of all the hard work and service our
students provide to others.”
The Follies is sponsored by the
Undergraduate American Academy
of Osteopathy. Last year, the event
raised nearly $2,000 for community
organizations.
4/23/20103:11:15PM
Bureau for Public Health | NEWS
West Virginia Health Statistics Center Child Asthma
Survey Enables Development of State Asthma Plan
Good data can lead to meaningful
plans for action. Physicians are
critical partners when it comes to
actions that will make a difference
in addressing the burden of asthma
on our citizens. Asthma is a serious,
sometimes life-threatening respiratory
disease that affects the quality of life
for millions of Americans. According
to the 2008 Behavioral Risk Factor
Surveillance System (BRFSS), an
estimated 9.6% (138,000) of adults
and 11.5% (43,000) of children in West
Virginia currently have asthma.
The West Virginia Health Statistics
Center (HSC), in collaboration with
the CDC, maintains the Behavioral
Risk Factor Surveillance System
(BRFSS), a state-based system
of health surveys that collects
information on health risk behaviors
and health conditions. In the past,
only limited data on asthma in adults
aged 18 years and older have been
available through BRFSS. In order to
increase the data available on asthma,
the Centers for Disease Control and
Prevention (CDC) converted the
National Asthma Survey to a callback survey administered nationally
as part of BRFSS in 2005. HSC began
conducting the BRFSS Adult and
Child Asthma Follow-up Surveys
annually in 2007. These surveys
better define the burden of asthma
in West Virginia by providing
new information on asthma, such
as demographics, recent asthma
history, symptoms and episodes,
health care utilization, knowledge of
asthma management, modification
to environment, medications,
costs of care, work/school related
asthma, and alternative therapies.
Prior to 2007, the only data
available for children with asthma in
West Virginia was the BRFSS Child
Prevalence Module. This module
only provided prevalence numbers
for children with asthma in West
Virginia. Using the data available in
this new survey, the West Virginia
Asthma Education and Prevention
Program (WVAEPP) has developed
“A Strategic Plan for Addressing
Asthma in West Virginia, 2010-2014”
available online at : http://www.
wvasthma.org/AboutTheAEPP/
AsthmaStrategicPlan/
tabid/1227/Default.aspx
This plan not only targets reducing
the burden of asthma in adults, but
also in children. A major goal in this
plan is to teach West Virginians with
asthma to self-manage symptoms
effectively. Data from the 2007 and
2008 BRFSS Child Asthma Call-back
Surveys were used for planning
interventions that would increase
self-management in West Virginians
with asthma. Regular visits to a health
care professional are essential in
asthma control, however only 64%
of children with asthma reported
visiting their healthcare provider
at least twice in the past 12 months.
The National Heart, Lung, and Blood
Institute (NHLBI) recommends the
use of a spacer/holding chamber
when taking inhaler medication,
but in West Virginia only 45% of
children reported using a spacer with
their inhaler medication. Another
recommendation of the NHLBI
is annual flu vaccine regardless
of asthma severity, however less
than half of West Virginia children
reported receiving their annual flu
vaccine in the past 12 months. This
and other data available in the BRFSS
Asthma Call-back Surveys can be
used to help WVAEPP, physicians,
and others determine what is
needed to help children with asthma
breathe easier in West Virginia.
Additional information on
BRFSS and other HSC products
and services is available at: www.
wvdhhr.org/bph/hsc/statserv/
BRFSS.asp. For more information
on asthma in West Virginia you
can visit WVAEPP’s website at:
http://www.wvasthma.org.
Sharon Hill
Asthma Epidemiologist
Health Statistics Center
May/June 2010 | Vol. 106 51
4/23/20103:11:20PM
Physician Practice Advocate | NEWS
Customer Service in the Medical Office
The importance of customer
service has recently become more
of a focus and priority for medical
practices. Numerous articles
have been written on the topic,
including one that appeared in the
New England Journal of Medicine.
At our recent Physician Practice
Conferences, the session led by
Certified Etiquette and Protocol
Consultant, Pam Harvit, “Office
Protocol and Etiquette,” has become
one of the highest rated sessions.
Why all this emphasis on medical
etiquette and good customer
service? Why should practices
be concerned about the etiquette
involved in treating patients?
Better yet, how does your practice
measure up customer service wise?
It’s just plain common business
sense that any medical practice
can ill afford to do without.
One reason for stressing the
importance of good customer service
in the medical office is based on a
very simple economic principle. With
changes in insurance plans and the
consumer-driven healthcare plans,
more patients are paying customers;
therefore, they are becoming more
knowledgeable about costs. As
informed consumers, they are more
likely to choose where they want
to receive their medical care.
More importantly, lack of etiquette
(otherwise known as rudeness!) may
actually increase the risk of liability
for a physician office. According to
a Harris study, a patient’s choice
to change physicians was often
not attributed to the medical care
received, but because of rude
treatment in the office. Research also
shows that happy patients generally
are less likely to sue. According
to a University of Texas study,
there is a clear association between
communication/respect of patients
and the incidents of lawsuits.
Finally and most importantly,
your customers are people first and
patients second and they deserve to
be treated as such. Good manners
and good customer service in the
medical office can help to emphasize
the importance of patient satisfaction
and professionalism among all
staff in the medical profession.
Most practices would like to
believe that their patients experience
the best care in their offices; not
only the clinical care, but the care
encountered during every step of
the patient’s medical office visit.
Here are some questions that all
practices should ask themselves
if they want to improve their
clinical customer service skills.
1. Is the staff acknowledging and
greeting each patient as he/she
enters the practice? This is very
important as first impressions
are lasting impressions!
2. Are patients being advised if
the physician is running behind?
Often, a very simple explanation
and apology upfront will alleviate
the developing anger that a
patient may experience as he or
she waits to see the physician.
3. Does everyone on the staff wear
a nametag? Do those who have direct
patient contact introduce themselves
and explain their role in the treatment
process? This is important to the
patient so that he/she is aware of
the function of each staff member.
4. Does the staff really listen to
the patients (even a complaining
one)? This indicates to the patient
that he/she is important and that
the practice cares for him/her.
5. Finally, does anyone on the
staff tell the patient “thank you”
as he/she leaves? This simple
phrase can make a huge difference
in how the patient perceives
his/her treatment. Remember—a
happy patient is generally a more
satisfied and compliant patient.
While this list of suggestions
is by no means a complete list,
perhaps it can serve as a starting
point for offices to look at ways to
improve their patient relationships.
It also gives you the opportunity
to see how your practice measures
up in customer service.
It is important to remember
that quality customer service
is becoming increasingly more
important in today’s society and
that patients are your customers.
With all the emphasis on state of the
art medical equipment, electronic
health records, the latest technology
and the most highly skilled staff,
we should not lose sight of the fact
that in the medical office, patients
should be the number one priority.
Utilizing good manners and good
customer service skills can ensure
that your staff presents themselves
as compassionate and caring
professionals who represent quality
medical care to your patients.
On a personal note, I recently
visited a large teaching hospital
where I observed the attitude of the
medical staff toward their patients
and family members. One of the
most noticeable observations was
the caring and friendly greetings
that were given, from the volunteer
at the information desk, patient
reception clerks, medical assistants,
4/23/20103:11:21PM
Physician Practice Advocate | NEWS Continued
nurses and physicians. Every patient
was treated as a person first and
a patient secondly. I listened as
patients and families in the waiting
area discussed the friendliness of
the staff. The positive comments
provided a refreshing reassurance to
newer patients and their families.
When a physician was running
behind, a staff member (always with
a name tag) came into the waiting
room to give a brief explanation, and
advised the patients as to the delay.
She assured each patient that the
physician would give him/her the
same time consideration when he
or she went back to the examining
room. She offered a restaurant style
pager to patients who wished to visit
the cafeteria or just wait in another
area of the clinic. Finally, as patients
were leaving the clinic after their
appointments, they were given a
friendly “good bye” and “thank you
for being so patient with us today.”
Not surprisingly, most patients were
smiling as they left the facility.
As I thought about the overall
experience, it occurred to me that
much of the patients’ experience
depends on the courtesy shown
to them by the medical practice
staff. It would seem that the care
and concern shown for the overall
patient experience may have a
direct relationship on the patient’s
attitude toward the visit; therefore
increasing compliance and the
possible outcome of treatment.
It might be as simple as just
remembering that good customer
service is just remembering the
Golden Rule—“Do unto others as
you would have them do unto you.”
Barbara Good
WVSMA Physician Practice Advocate
| New Members
We would like to welcome the following physicians and medical students to the WVSMA:
Cabell County Medical Society
Kanawha County Medical Society
Ann Conjura, MD
Kathleen Bors, MD
Chitta Sarker, MD
Central West Virginia Medical Society
Kimberly Farry, MD
Monongalia County Medical Society
Eastern Panhandle Medical Society
John Lubicky, MD
Olusola Oduntan, MD
Rohma Shamsi, MD
Shannon Bentley, MD
Romulo Estigoy, MD
Parkersburg Academy of Medicine
Darcy Conner, DO
Please direct all membership inquiries to: Mona Thevenin, WVSMA Membership Director
Just a friendly reminder ...
Have you
renewed your 2010
WVSMA Membership?
May/June 2010 | Vol. 106 53
4/23/20103:11:22PM
Obituaries
The WVSMA remembers
our esteemed colleagues…
Alfred John Magee, MD
Lee H. Pratt, MD
Dr. Alfred John Magee,
90, of Charleston passed
away March 31, 2010.
Alfred was the son of Hugh
and Mary J Magee. He was born in
Jersey City, NJ, and was preceded
in death by his brothers, Edward,
Hugh, Joseph and George, and their
wives, as well as his sister, Mary.
He is survived by his wife of
56 years, Joyce, and leaves behind
his daughters and their husbands,
Louise and Jeff McClung and Susan
and John O’Brian; sons and their
wives, Harry and Elizabeth Magee,
Edward and Janet Magee, John
and Julie Magee and Richard and
Junko Magee; 11 grandchildren;
and many nieces and nephews.
He was an active member of
St. Agnes Catholic Church and
served in the U.S. Army. He
practiced ophthalmology for 32
years in Charleston and eight
years in Summersville and was a
clinical professor of ophthalmology
at West Virginia University.
He was a wonderful husband
and greatly loved father.
Memorial contributions may be
made to St. Agnes Catholic Church,
4801 Staunton Ave. SE, Charleston,
WV 25304, or a charity of your choice.
Dr. Lee H. Pratt, formerly of
Charleston, died Nov. 15, 2009,
in Okatie, S.C., at the age of 64.
Dr. Pratt and his wife, Bonnie, had
lived in the Hilton Head area of South
Carolina, since his retirement from
the practice of neurology in 2002.
He was a graduate of the
West Virginia University School
of Medicine and practiced in
Charleston since 1975. He was a
longtime boating enthusiast and an
officer of the Hilton Head Island
Power Squadron. He was also a
member of several motorcycling
groups, including HOG and the
Motorcycling Doctors Association.
At the time of his death, he was a
volunteer at the Hilton Head Island
“Volunteers in Medicine” Clinic.
He is survived by his wife, Bonnie;
three children, Travis, Tierney and
Trevor; and five grandchildren.
Carl J. Roncaglione, MD
Carl J. Roncaglione, MD, 87, of
Charleston died March 17, 2010.
Many knew him as “Doctor Ron”
or “Doctor Carl.” He was born
February 25, 1923, in the town of Oak
Hill, the second of six children of the
late Louis and Hazel Roncaglione.
He grew up in the mining towns of
Pocahontas, Virginia, and Amonate,
Virginia. He graduated from Big
Creek High School, War, WV, class of
1939. At Emory and Henry College,
Emory, Virginia, he graduated in
the class of 1943, with a B.A. degree
in chemistry and biology. At Notre
Dame University Midshipman School
he was commissioned an ensign
DVG USNR, and after Underwater
Demolition School, Fort Pierce,
Florida, and Amphibious School
in Patuxtent, Maryland, in 1944
he became skipper of USS L6T 879
(Landing Craft Tank) which made
multiple amphibious landings in
the battles of New Guinea, the
Leyte Gulf, Subic Bay, Lingayen
Gulf, Corregidor and Manila
in the Philippines in WWII.
After WWII he received his
medical degree followed by five
years residency in orthopedic
surgery at the Medical College of
Virginia, Richmond. His debut in
orthopedic surgery in Charleston
was July 1, 1956. He retired March
31, 2001. Orthopedic organizations
in which he participated and into
which he was inducted included
the American Board of Orthopedic
Surgery, the American Academy
4/23/20103:11:22PM
Obituaries | Continued
of Orthopedic Surgeons and the
American College of Surgeons.
He was a past president of the
Kanawha Medical Society, the West
Virginia State Medical Association,
the Tri-State Orthopedic Society,
and the West Virginia Board of
Education. He was a life member of
the Southern Medical Society, the
Republican National Committee,
BASS (Bass Anglers Sportsman
Society), a member of Masonic Lodge
No. 20 AF&AM for over 50 years, a
32nd degree Scottish Rights Mason,
and a member of the Beni Kedem
Shrine. He belonged to American
Legion Post 20. He was deeply
appreciative of the designation by
his colleagues as the West Virginia
Orthopedic Surgeon of the year
in 1955. His passions were small
mouth bass fishing, tennis and golf.
On June 25, 1949, he married
Tommie Ballard McCoy Roncaglione.
Her death on January 2, 2007, was
a devastating event from which he
never fully recovered. Doctor Carl
was preceded in death by his parents
and an older brother, Howard
Marshall Roncaglione; and a younger
brother, John Elwood Roncaglione.
Surviving are three sisters,
Virginia Roncaglione Courtney,
Shrewsbury, MA, Lillian Roncaglione
Bazzle, Williamsburg, VA, and
Betty Roncaglione Ball, Titusville,
FL. Surviving children include
Tommie Sue and Chet Roberts
of Charleston and their children,
Cheston and Eva; Katie and Robert
McKean of Lakeland, FL, and
their sons, Brock and Reed; and
Susan and Jim Roncaglione of
Charleston and their children, Carl
III, Louis, Sam, Willie, and Felix.
Memorial contributions may
be directed to Emory and Henry
College Development Office,
Emory, VA 24327-0905, Charleston
Baptist Temple, 209 Morris St.,
Charleston, WV 25301, or the
Medical College of Virginia, P.O. Box
0156, Richmond, VA 23298-0156.
Carl and his family express
their deepest and most sincere
thanks to his physicians, medical
caregivers and providers at CAMC
Charleston Memorial Hospital,
Drs. Hamrick, Alasadi, Nellhaus,
Thalheimer, Lily, and Ridenour,
Dr. Pfister, the CAMC staff on the
Surgical Intensive Care Unit, and
the CAMC Staff on Four North.
Dr. and Mrs. Charles P. Winkler; his
Charles Winkler Jr., MD
be sorely missed by his family.
Charles Pinckney Winkler Jr.,
MD, 53, of Richmond, died April
7, 2010. He is survived by his two
children, Jennifer W. Winkler and
Charles P. Winkler III; his parents,
sisters, Kathryn W. Nicholas and
Carol W. Lormand and her husband,
Michael; two nephews, Jamie
Nicholas and Dylan Lormand; his
uncle and aunt, Dr. and Mrs. Moseley
Winkler, and cousins, Kristy Zak,
Adele Holmes, Ann Holbrook and
Betsy Willis; his aunt, Betty Roberts,
and cousins, Holly Morgan, Scott
Roberts, Nancy Talaba and James
Winkler. Born October 11, 1956 in
Richmond, Va., Chuck graduated
from St. Christopher’s School and
the University of Virginia, with
distinction from both. He received
his M.D. from the Medical College
of Virginia, completed a residency
in obstetrics and gynecology in
1990, and practiced in Charleston,
West Virginia, for the next 20 years.
He was a Fellow of the American
College of OBGYN. Chuck was
loved by his patients and respected
by his peers. He was a beloved
son, brother and father and will
The family requests that, in lieu
of flowers, donations be made
to the St. Christopher’s School
Foundation, 711 St. Christopher’s
Rd., Richmond, VA 23226.
The West Virginia Medical Journal is honored to publish the obituaries of West Virginia
physicians. Please send copy to:
Angie Lanham
Managing Editor, WV Medical Journal
PO Box 4106
Charleston, WV 25364 or
E-mail to: [email protected]
May/June 2010 | Vol. 106 55
4/23/20103:11:22PM
WV Medical Insurance Agency | NEWS
Introducing: Dave J. Mueller,
Physician Services Specialist
Dave J. Mueller
In the summer of 2009, the
West Virginia Medical Insurance
Agency made a pledge to its clients
in the form of an emphasis on its
services by introducing the tag
line of “Valued Assistance.” We
explained that “Valued Assistance”
reflected our promise to our clients
to improve their overall insurance
position when utilizing our services.
A major step in reinforcing this
promise has recently occurred at
the WVMIA with the hiring of
Dave Mueller, as Physician Services
Specialist, effective April 1, 2010.
Dave Mueller is a native West
Virginian, returning home (his
hometown is Huntington) to
accept a position with the West
Virginia Medical Insurance
Agency that will allow him to
bring his out-of-state medical
professional liability experiences
to provide “Valued Assistance”
to West Virginia physicians.
Most recently Dave has been a
senior account executive with MAG
Mutual Insurance Company, the
largest physician owned insurer in
the Southeast and the director of
medical relations and marketing for
The MD Company of Alpharetta,
Georgia. The MD Company’s
services included the provision of
physician practices with education
and strategies to improve patient
care and reduce practice costs.
During his nine years with MAG
Mutual, Dave was responsible for
client relationship management
servicing physicians, surgeons, and
health care administrators. Dave
achieved a 90%+ customer retention
rate for 8+ years by fostering and
solidifying relationships with
physicians and administrators.
While at MAG Mutual, Dave
actively participated in the Georgia
physicians’ 2005 tort reform “White
Coat Day” and other efforts to bring
tort reform to the State of Georgia.
“Dave will add knowledge and
depth to our physicians’ insurance
team with the West Virginia
Medical Insurance Agency. He is
an excellent choice to assist the
Agency further in its commitment
of “Valued Assistance” to our
clients throughout West Virginia.
With Dave’s unique set of skills and
knowledge of medical professional
liability insurance, we expect him
to work well with the physicians of
West Virginia” said Steve Brown,
WVMIA, Agency Manager.
Dave also has experience working
with physicians on a more direct
basis as he worked with IntraOptics
and with Ocudyne in regional and
national management positions
establishing a series of physician
education courses that focused on
The Agency production staff, Dave Mueller, Steve Brown and Graham Reger, discuss marketing strategies.
4/23/20103:11:27PM
WV Medical Insurance Agency | NEWS Continued
the then latest surgical developments
and techniques in eye surgery.
Dave’s role with the West Virginia
Medical Insurance Agency will be to
provide “Valued Assistance” in the
form of medical professional liability,
workers’ compensation, business
owners, employment practices and
directors’ and officers’ insurance
products as well as other insurance
products offered to physician clients.
The West Virginia Medical
Insurance Agency is a wholly owned
subsidiary of The West Virginia State
Medical Association; its only clients
are physicians; therefore, its “Valued
Assistance” is specifically directed
to its client base of physicians
only. West Virginia Medical
Insurance Agency was established
in 2004 and currently is one of
West Virginia Mutual Insurance
Company’s largest producers,
representing more than 300 doctors
in the State of West Virginia.
Please welcome Dave Mueller back
to his home state as he works with
us to achieve our goal of “Valued
Assistance” to the physicians
of the state of West Virginia.
Dave Mueller may be contacted at
the Agency by calling 1-800-257-4747
ext 29 (locally at 304-925-0342 ext 29)
or by e-mail at [email protected].
its parent organization, the West
Virginia State Medical Association,
is super. The Association helps
doctors in so many ways, and I
hope to do my part to be involved
in as many medical conferences and
educational programs as possible. In
my new position with the Agency,
I know I can help doctors improve
their position in the market. I have
worked with doctors and their
office administrators for over 20
years in various capacities, but
my new role as Physician Services
Specialist is a unique, once-in-alifetime opportunity that will be
both challenging and rewarding.”
“I plan to hit the ground running
and help surgeons and physicians
with their practice and personal
insurance needs. In the past, the
professional liability market has
been volatile. Doctors were leaving
the state and patients were finding
it more difficult to find access to
complete health care. But since the
passage of tort reform in WV in
2003, and the formation of the West
Virginia Mutual Insurance Company,
rates have steadily decreased.
Doctors have now returned to WV,
and patients have better access to
all health care specialties. Through
the Agency, we can help doctors
with their insurance risk and the
business-side of medicine so that
they can focus on quality patient
care. It is truly a win-win situation
for our doctors and their patients.”
Good to be home...
“It’s very special and exciting to
now be apart of the West Virginia
Medical Insurance Agency’s
professional team. The Agency
does an excellent job serving the
physicians of West Virginia, and I’m
very fortunate to be apart of their
commitment to professionally serving
the doctors of our great state. Steve
Brown and his staff have made me
feel so welcome to be back home, and
I’m looking forward to working with
doctors and fulfilling the Agency’s
pledge of providing “Valued
Assistance” while helping physicians
with their medical practice needs.
It’s great working with doctors and
helping them secure the right level of
coverage at the best possible price.”
“Coming home to West Virginia
and working with the Agency and
Dave Mueller
Physician Services Specialist
Welcome
Dave Mueller, Physician Services Specialist
Dave Mueller joins the staff of the West Virginia Medical Insurance Agency,
returning home to West Virginia after serving physicians in the Southeastern
United States for the past 11 years.
Steve Brown (right), Agency Manager,
welcomes Dave Mueller (left) as Dave begins
his role as Physician Services Specialist with
the Agency.
To Contact Dave Mueller
Call:
1-800-257-4747 ext. 29
|
Fax: 1-304-925-3166
Email: [email protected]
May/June 2010 | Vol. 106 57
4/23/20103:11:29PM
St. Jude patient Brook (center) with her sisters
Honor a friend . . .
Remember a loved one.
Honor the accomplishments of a friend or remember a loved one by
making a donation in their name to St. Jude Children’s Research Hospital,
one of the world’s premier pediatric cancer research centers.
Give the gift of life to children around the world.
St. Jude Children’s Research Hospital
Memorials and Honors
P.O. Box 1000, Dept. 142
Memphis, TN 38148-0142
1-800-873-6983
www.stjude.org/tribute
4/23/20103:11:29PM
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May/June 2010 | Vol. 106 59
4/23/20103:11:32PM
Manuscript Guidelines
Originality: All scientific and special topic
manuscripts for the West Virginia Medical Journal will
not be considered for publication if they have already
been published or are described in a manuscript
submitted or accepted for publication elsewhere. All
scientific articles should be prepared in accordance
with the “Uniform Requirements for Submission of
Manuscripts to Biomedical Journals.” Please go to
www.icmje.org for complete details.
Authors: A cover letter from the corresponding
author should be submitted with the manuscript. All
persons listed as authors should have participated
sufficiently in the work to take public responsibility for
the concept.
Format: All articles may be submitted by email or on
CD. Microsoft Word is preferred, but other programs
are acceptable. All tables or figures should be
created separately from the body of the manuscript
as .tif, .jpg or .pdf files in a high resolution format with
corresponding file names such as, Table 1, Figure 1,
etc. Legends should be included for all tables and
figures.
References: References should be prepared in
accordance to the “American Medical Association
Manual of Style.” These instructions for authors are
available online at www.jama.com.
Photographs: Please submit high resolution digital
files with an image size of 300 dpi at 100% of size.
This high resolution size must be equal to 2.5” by 2.5”
minimum size. Low resolution photos may be
rejected or print with poor quality.
Note to authors: The WV Medical Journal inside pages
traditionally print in black and white. If authors wish to
have photos and figures printed in color, there is a
$1,000 charge per article to help defray the printing
costs to the Association. Please indicate your preference
when submitting an article. If your article is accepted for
publication, you will be invoiced for the charges in
advance of publication.
Please address articles and cover letter to the editor at
this address only:
F. Thomas Sporck, M.D., F.A.C.S.
Editor
P.O. Box 4106
or email your article with cover letter to:
Angela L. Lanham, Managing Editor
[email protected]
Thanks To Our Advertisers!
Alpha Financial Solutions.................................................59
CAMC Health Ed. and Research Institute..........................1
Chapman Printing Co........................Inside Back Cover, 59
CPR Solutions Group, Inc..................................................2
Ear, Nose & Throat Assoc. of Charleston, Inc..................10
Flaherty Sensabaugh & Bonasso PLLC...........................27
HIMG................................................................................20
Madison Medical, PLLC...................................................59
McLain Surgical Supply....................................................59
Office Managers Association............................................47
Physician’s Business Office..............................................17
Stationers, Inc..................................................................59
Suttle & Stalnaker.............................................................29
Unicare...............................................................................7
West Virginia Medical Insurance Agency.........................57
West Virginia Mutual Insurance Co................... Back Cover
West Virginia University.......................... Inside Front Cover
Advertising Policy
The WVSMA reserves the right to deny advertising space to any individual,
company, group or association whose products or services interfere with
the mission, objectives, endorsement agreement(s) and/or any contractual
obligations of the WVSMA. The WVSMA, in its sole discretion, retains the
right to decline any submitted advertisement or to discontinue publishing any
advertisement previously accepted. The Journal does not accept paid political
advertisements.
The fact that an advertisement for a product, service, or company appears
in the Journal is not a guarantee by the WVSMA of the product, service or
company or the claims made for the product in such advertising. The WVSMA
reserves the right to enter into endorsements, sponsorship and/or marketing
agreements that may limit the placement of advertisements for certain
products or services.
Subscription Rates:
$60 a year in the United States
$100 a year in foreign countries
$10 per single copy
POSTMASTER: Send address changes to the West Virginia
Medical Journal, P.O. Box 4106, Charleston, WV 25364.
Periodical postage paid at Charleston, WV.
USPS 676 740 ISSN 0043 - 3284
Claims for back issues should be made within six months after
publication. Microfilm editions beginning with the 1972 volume are
available from University Microfilms International, 300 N. Zeeb Rd.,
Ann Arbor, MI 48106.
©2009, West Virginia State Medical Association
4/23/20103:11:33PM
Inside back
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4/23/2010 3:14:53 PM
BACK COVER
P.O. Box 4106
www.wvsma.com
Experience. Success. Teamwork. Commitment.
The Mutual provides you access to a successful,
local claims management team with a thorough
understanding of the fragile West Virginia
malpractice market.
During our five years of operations, your
Mutual has a ninety-two percent success ratio
when cases are taken to trial.
We win cases on behalf of our physician owners.
We are your advocate.
We are your company.
We are your Mutual.
500 Virginia Street, East
Suite 1200
(304) 343-3000
(304) 342-0985 fax
(888) 998-7642
www.wvmic.com
4/23/2010 3:14:56 PM

May/June - West Virginia State Medical Association

Transcription

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